PAUL   B.HOEBER 

MEDICAL  BOOKS 

69E.5  9thSt.,N.Y. 


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BOOKS 

BY 

JAMES  G.   MUMFORD,   M.D. 


A  NARRATIVE  OF  MEDICINE  IN  AMERICA.  1903 

CLINICAL  TALKS  ON  MINOR  SURGERY,  1903 

SURGICAL   ASPECTS    OF    DIGESTIVE    DIS- 
ORDERS.                                               1905  and  1907 

SURGICAL  MEMOIRS  AND  OTHER  ESSAYS.  1908 

THE  PRACTICE  OF  SURGERY.  1910 

ONE  HUNDRED  SURGICAL  PROBLEMS,  1911 


THE 
CASE  HISTORY  SERIES 


CASE   HISTORIES   IN   MEDICINE 

BY 

Richard  C.  Cabot,  M.D. 

Second  edition,  revised  and  enlarged 


CASE   HISTORIES   IN    PEDIATRICS 

BY 

John  Lovett  Morse,  M.D. 


ONE   HUNDRED   SURGICAL   PROBLEMS 

BY 

James  G.  Mumford,  M.D, 


CASE   HISTORIES   IN   NEUROLOGY 

EY 

E.  W.  Taylor,  M.D. 


ONE   HUNDRED 


Surgical  Problems 


THE  EXPERIENCES  OF  DAILY  PRACTICE 
DISSECTED  AND   EXPLAINED 


BY 


JAMES   G.   MUMFORD.  M.D. 

Visiting  Surgeon  to  the  Massachusetts  General  Hospital; 

Instructor  in  Surgery,  Harvard  Medical  School ; 

Fellow  of  the  American  Surgical 

Association,  etc. 


BOSTON 

W.  M.  LEONARD,  PUBLISHER 
1911 


Copyright,  It^ll, 
By   IV.  M.  Leonard. 


PREFACE. 


The  teachings  of  practice  are  conveyed  by  example  as  well  as 
by  precept.  Until  recent  years  writers  knew  and  availed  themselves 
of  this  fact.  They  set  forth  their  lessons  by  case  illustrations. 
Galen  did  this;  so  did  Pare,  —  that  master  of  the  method;  so  did 
Wiseman  and  Le  Dran,  Hunter  and  Petit,  Cooper  and  Paget.  The 
method  in  proper  hands  is  luminous,  and  the  lessons  are  instantly 
comprehensible.  We  abused  and  nearly  lost  that  method  with  the 
development  of  the  statistical,  analytical  practice  of  the  last  century. 

Three  years  ago  Richard  C.  Cabot,  following  the  suggestions  of 
Cannon,  and  Burrell  and  Blake,  saw  the  advantage  of  the  old 
teaching  by  cases  and  wrote  a  little  book  about  it.  Others  are 
following  his  example,  each  man  illustrating  his  specialty. 

This  book,  too,  is  another  such  publication.  I  have  collected 
one  hundred  surgical  cases,  each  one  either  a  problem  or  an  illustra- 
tion of  important  features  in  diagnosis  and  treatment.  Many  of 
the  cases  are  homely  and  commonplace.  Obviously  the  names 
given  to  the  patients  are  fictitious.  Perhaps  the  reader  will  recog- 
nize the  situations,  and,  for  the  solution  of  his  own  troubles,  will 
turn  to  account  the  struggles  of  another. 

J.  G.  M. 


TABLE    OF    CONTENTS. 


PAGE. 

Cases      1-7.  The  Stomach  and  Duodenum 9 

8.  Acute  Infection 29 

9,  10.  "  Seizures  " 31 

1 1 .  Exploratory  Laparotomy 37 

12.  Perforated  Abdomen 41 

13.  Sterility      45 

14-16.  The  Breast 47 

17-20.  Digestive  Disorders 55 

21-23.  Dyspepsia      65 

24-26.  Gynecology 75 

27-30.  The  Head 85 

31-33.  The  Kidney 97 

34, 35.    Empyema      107 

36.  Intestinal Ill 

37-39.  The  Bones 113 

40-42.  Hernia 121 

43-48.  The  Liver  and  Ducts       129 

49,  50.  Gestation 151 

51-63.  Digestive  Disorders 159 

64.  Borderland  Case 199 

65-72.  Toxemias 203 

73-75.    Chronic  Indigestion 233 

76-79.    "  Indigestion  " 243 

80,  81.    Borderland  Cases 259 

82-86.    Abdominal,  General 267 

87.  The  Uterus 283 

88.  Intestinal  Obstruction 287 

89-92.    The  Pelvis 291 

93-95-    The  Bowel 305 

96.  The  Scrotum 317 

97.  Genito-Urinary 321 

98,  99.    Abdominal  Adhesions 325 

100.    Genito-Urinary 333 


ONE   HUNDRED 
SURGICAL   PROBLEMS. 


THE   STOMACH   AND    DUODENUM. 

Case  I.  Angus  McPherson,  an  active  Scotch  gardener  of 
thirty-six,  entered  my  wards  at  the  Massachusetts  General 
Hospital  in  July,  1910.  He  was  somewhat  disturbed  by  the 
fact  that  both  his  father  and  mother  had  died  of  cancer  of 
the  stomach.  His  own  early  history  had  been  rather  stormy, 
with  ten  years  of  troublesome  dyspepsia  ^  after  he  attained 
his  growth.  He  was  a  moderate  drinker  of  whiskey,  but  his 
habits  were  otherwise  good.  He  was  married,  and  the  father 
of  four  children.  For  ten  years  back,  while  able  to  perform 
continuous  and  laborious  work,  he  had  been  disturbed  by 
almost  daily  distress  after  food, —  distress  coming  on  about 
an  hour  and  a  half  ^  after  the  meal,  and  always  relieved  by 
food  or  the  drinking  of  water.  On  one  occasion,  some  two 
years  back,  he  vomited  what  looked  like  blood. ^  His  notable 
contribution  to  the  history  of  his  own  case,  however,  was  the 
frank  statement  that  one  year  previously  he  had  been  oper- 
ated upon  by  gastroenterostomy  for  duodenal  ulcer.^  For 
three  months  after  the  operation  he  felt  well  and  without 
any  of  his  old  symptoms.  During  the  past  nine  months 
however,  digestive  disturbances  recurred,  and,  at  the  time 
of  entering  the  hospital  he  was  the  victim  of  frequent  sick 
headaches  in  the  early  morning,  with  obstinate  constipation^ 
gastric  distress  and  flatulence  about  two  hours  after  taking 
food,  occasional  vomiting  of  food  only,  and  a  general  condi- 
tion which  he  described  as  "no  good." 

The  physical  examination  of  this  man  was  curiously  incon- 
sistent with  his  story.  He  appeared  tall,  vigorous,  well 
nourished  and  of  a  ruddy  countenance;  his  speech  and  bear- 
ing were  not  those  of  an  invalid.  His  temperature  was  98.4; 
pulse  66.  All  his  discomfort  was  referred  to  the  epigastrium, 
which  was  slightly  distended  and  was  tender  on  pressure  every- 
where between  the  costal  arch  and  the  navel. ^  There  was 
tenderness  also  in  the  right  costovertebral  angle,  with  oc- 
casional pain  shooting  thence  up  towards  the  right  shoulder.^ 

9 


lO  SURGICAL   PROBLEMS. 

An  analysis  of  his  gastric  content  showed  hyperchlorhydria, 
with  a  trace  of  blood,  while  a  fecal  movement  secured  by 
enema  showed  also  a  considerable  trace  of  blood. ^  The  urine 
was  not  abnormal;  there  was  no  mass  to  be  felt  anywhere  in 
the  abdomen ;  no  tenderness,  rigidity  or  spasm,  except  in  the 
epigastrium;  and  no  jaundice  was  present. 

The  patient  was  convinced  that  in  some  way  his  previous 
operation  had  broken  down  and  that  he  could  be  cured  by  a 
second  operation  only. 

^  Ten  years  of  dyspepsia,  presumably  not  relieved  by 
treatment,  suggests  strongly  some  anatomical  lesion  in  the 
stomach  or  duodenum,  the  bile  passages,  the  pancreas,  the 
right  kidney  or  the  appendix  vermiformis. 

^  Distress  coming  on  an  hour  and  a  half  after  meals  suggests 
a  lesion  of  the  pylorus,  or,  more  properly,  of  the  duodenum. 
We  are  satisfied  that  many  cases  which  have  been  called  gas- 
tric ulcer  should  be  called  duodenal  ulcer,  the  lesion  commonly 
being  a  mere  crack  or  fissure  of  the  mucosa  beyond  the  pyloric 
sphincter. 

^  The  vomiting  of  blood  suggests  gastric  or  duodenal  ulcer, 
cancer,  cardio-renal  disease,  or  hepatic  cirrhosis;  but  the 
vomiting  of  blood  once  only  suggests  as  most  likely  a  source 
of  hemorrhage  beyond  the  pylorus.  Duodenal  ulcer,  however, 
is  not  an  uncommon  cause  of  hematemesis. 

^  The  surgeon  thinks  of  two  forms  of  gastro-enterostomy, 
the  posterior  and  the  anterior.  The  posterior  is  the  more 
commonly  employed,  especially  in  young  men  who  are  oper- 
ated upon  for  non-malignant  disease.  Anterior  gastro-enter- 
ostomy is  employed  generally  to-day  in  cases  of  gastric 
cancer.  One  considers  the  causes  of  recurrence  of  symptoms 
after  a  presumable  posterior  gastro-enterostomy, and  concludes 
that  a  partial  closure  of  the  stoma,  or  opening  between  the 
stomach  and  jejunum,  would  account  for  their  recurrence. 
We  have  no  detailed  account  of  gastro-enterostomy  performed 
in  this  man's  case,  but  may  assume  that  after  its  performance, 
and  the  healing  of  the  ulcer,  the  pylorus  became  freely  patent, 
the  stoma  became  closed,  and  conditions  which  encouraged 
a  return  of  the  duodenal  ulcer  recurred. 

^  Pain  and  tenderness  in  the  epigastrium  suggest  gastric 
or  duodenal  ulcer,  disease  of  the  pancreas  or  disease  of  the 
bile  passages. 

^  Tenderness  at  the  right  costovertebral  angle  suggests 
strongly  some  lesion  of  the  right  kidney,  though  this  pain  is 


STOMACH   AND   DUODENUM.  II 

sometimes  seen  in  gall-bladder  disease,  in  disease  of  the  pan- 
creas and  in  disease  of  the  duodenum.  Pain  radiating  towards 
the  right  shoulder  suggests  especially  a  gallstone  endeavoring 
to  escape  through  the  cystic  duct. 

^  Traces  of  blood  found  in  the  vomitus  and  in  the  stools 
by  the  guaiac  test  are  not  always  significant,  as  the  presence 
of  animal  foods  may  be  detected  by  this  extremely  delicate 
test  for  blood. 

When  we  considered  his  positive  history  of  gastro-enter- 
ostomy  for  duodenal  ulcer,  and  the  recurrence  of  symptoms 
after  the  operation,  we  felt  a  reasonable  assurance  that  the 
diagnosis  of  the  present  condition  must  in  some  way  rest  upon 
the  previous  gastro-enterostomy.  I  decided,  therefore,  to 
explore  the  man's  abdomen,  with  the  conviction  that  some 
anatomical  derangement  might  be  discovered  there  which 
would  give  us  the  key  to  the  symptoms. 

The  operation  disclosed  a  peculiar  form  of  post-operative 
hernia,  a  condition  which  is  described  in  all  text-books,  but 
is  not  commonly  seen  by  operating  surgeons.  Immediately 
on  opening  the  abdomen  the  stomach  was  discovered  pressed 
forward  against  the  anterior  abdominal  wall,  while  behind 
and  below  it  there  were  felt  tympanitic  and  bulging  intestines. 
I  turned  up  the  omentum  and  transverse  colon  and  revealed 
a  coil  of  greatly  distended  and  injected  jejunum  caught  be- 
tween the  folds  of  the  gastrocolic  omentum.  The  reader 
knows  that  in  performing  a  primary  posterior  gastro-enter- 
ostomy, when  the  omentum  is  turned  up,  the  surgeon  cuts 
through  the  posterior  layer  of  the  gastrocolic  omentum,  in 
order  to  reach  the  stomach.  Through  this  cut  in  the  omentum 
the  loop  of  jejunum  is  passed  for  its  anastomosis  with  the  stom- 
ach. The  omental  rent  should  always  be  closed  by  stitching 
it  to  the  stomach  before  completing  the  operation.  It  appears 
that  in  the  case  under  discussion  my  predecessor  had  failed 
to  observe  this  precaution  of  stitching.  Consequently  there 
was  left  alongside  the  jejunum  a  considerable  channel,  or 
rent,  through  which  free  portions  of  the  jejunum  burrowed 
as  a  hernia  into  the  lesser  peritoneal  cavity.  That  segment 
of  the  jejunum  which  rested  against  the  artificial  omental 
ring  had  become  greatly  constricted.    As  a  result,  the  hernial 


12  SURGICAL  PROBLEMS. 

portion  of  the  gut  was  greatly  congested  and  partially  strangu- 
lated, while  all  the  distal  portions  of  the  intestinal  canal 
appeared  pale,  thin  and  contracted.  Doubtless  the  condition 
of  the  hernia  fluctuated  from  day  to  day,  and  possibly  from 
hour  to  hour.  I  withdrew  the  jejunum,  reducing  the  hernia, 
sewed  up  the  rent  in  the  omentum  and  stitched  the  omentum 
snugly  to  the  posterior  wall  of  the  stomach. 

During  the  third  week  of  the  patient's  convalescence  further 
evidence  of  obstruction  necessitated  another  opening  of  the 
abdomen,  when  some  troublesome  adhesions  were  freed.  Sub- 
sequently he  was  transferred  to  the  medical  wards  to  be  "  built 
up."     He  is  now  well.* 


*A  pleasant  account  of  this  case,  assigning  all  credit  for  the  patient's  cure  to  his  treatment  in 
the  medical  wards  of  the  hospital,  is  given  in  a  recent  number  of  the  Boston  Medical  and  Surgical 
Journal. 


STOMACH   AND   DUODENUM.  1 3 

Case  2.  Early  in  1905  a  physician  asked  me  to  see  in 
consultation  his  sister,  a  woman  thirty-live  years  of  age  and  a 
school-teacher.  She  was  the  victim  of  frequent  severe  occipital 
headaches,  —  headaches  so  exhausting  that  she  was  some- 
times confined  to  her  bed  by  them  for  a  week  at  a  time.  Her 
health  was  becoming  undermined  and  she  had  abandoned 
her  work.  Until  the  summer  of  1899,  six  years  before  I  saw 
her,  the  patient  had  been  in  excellent  health,  but  now  her 
physical  breakdown  was  becoming  increasingly  grievous. 
In  addition  to  the  headaches,  she  suffered  from  blurring  of 
vision,^  attacks  of  nausea  and  occasional  sensations  of 
distress  and  heaviness  in  the  upper  portion  of  the  abdomen.^ 
These  disturbances  had  become  more  frequent  during  the 
preceding  three  months,  and  on  half  a  dozen  occasions  she 
had  been  overwhelmed  with  violent  attacks  of  vomiting, 
vomiting  great  amounts  of  food,^  as  from  an  overloaded  stom- 
ach. In  the  course  of  six  years  her  weight  had  fallen  from 
130  to  no,  and  she  had  become  the  victim  of  a  pronounced 
melancholy.  At  the  time  I  saw  her  she  was  in  the  sixth  day 
of  one  of  her  attacks  of  headache  and  nausea.  She  complained 
then  of  pain  following  almost  immediately  after  the  taking  of 
all  food,*  and  of  constant  nausea.  She  stated  that  for  a  week 
she  had  lived  on  a  scanty  allowance  of  peptonized  milk. 
She  was  constipated,  obtaining  a  movement  of  the  bowels 
but  once  a  week,  and  then  by  the  use  of  calomel.  She  had 
never  been  jaundiced,  and  the  urine  was  found  to  be  not 
abnormal. 

In  appearance  this  woman  was  an  invalid  with  a  long 
history.  She  was  sallow,  and  there  was  a  pronounced  second- 
ary anemia,  with  obvious  emaciation.  While  an  examination 
of  the  chest  was  negative,  an  examination  of  the  abdomen 
was  interesting  and  significant.  The  patient  stood  with 
rounded  back,'^  flat  dorsal  spine  and  stooping  shoulders; 
the  lower  portion  of  her  abdomen  was  distinctly  protuberant, 
while  the  stomach  on  percussion,  after  inflation  with  air, 
appeared  to  be  enlarged  to  at  least  twice  its  normal  size,  and 
its  lower  border  to  sink  three  inches  below  the  navel. ^  Al- 
though the  stomach  gave  this  appearance  of  distention  and 
sagging,  its  transverse  diameter  also  was  great,  for  the  gastric 


14  SURGICAL   PROBLEMS. 

tympany  reached  broadly  across  the  abdomen  ^ ;  the  right 
kidney  was  tender  and  palpable  ^ ;  there  was  tenderness  over 
the  appendix/  and  extreme  tenderness  in  the  epigastrium, 
where  the  abdominal  aorta  could  be  felt  vigorously  pulsating. 
No  mass,  however,  could  be  detected  anywhere  in  the  abdo- 
men. The  tongue  was  furred,  the  breath  offensive,  and  the 
aspect  of  the  patient  miserable  in  the  extreme. 

^  Blurring  of  vision  is  due  to  a  great  variety  of  causes, 
the  most  important  of  which  are  syncope,  cardiac  irregularity, 
arteriosclerosis,  renal  disease,  pelvic  disease,  disease  of  the 
eyes,  of  the  stomach,  of  the  liver  and  of  the  intestines,  and 
psychic  impressions.  The  association  of  gastric  symptoms 
with  blurring  of  vision  in  this  case  suggests,  of  course,  some 
stomachic  derangement. 

^  A  sense  of  heaviness  in  the  upper  part  of  the  abdomen 
is  due  commonly  to  an  overloaded  stomach,  whether  from 
overeating  or  as  a  result  of  pyloric  obstruction;  to  gastritis, 
to  delayed  gastric  motility  and  to  new  growths. 

^  The  vomiting  of  great  amounts  of  food  is  usually  due  to 
one  of  two  conditions.  The  common  cause  is  overeating, 
and  is  frequently  seen  in  the  cases  of  children  and  young 
persons.  The  second  cause  is  pyloric  obstruction  which 
results  directly  from  dilatation  of  the  stomach  to  a  greater 
or  less  degree,  to  the  accumulation  of  food  in  that  organ, 
and  to  its  ejection  from  time  to  time  in  enormous  amounts, 
so  that  the  patient  may  recognize  food  taken  twenty-four 
to  thirty-six  hours  previously. 

*  Common  causes  of  epigastric  pain  following  immediately 
after  eating  are  gastritis  and  gastric  ulcer.  At  the  same  time, 
one  recollects  that  disease  of  the  pancreas,  disease  of  the  bile 
passages,  and  even  disease  of  the  right  kidney  may  result 
in  pain  immediately  after  the  eating  of  food,  which  distends 
the  stomach  and  presses  upon  those  organs. 

^  The  peculiar  position  assumed  by  this  patient  always 
suggests  a  visceral  ptosis  —  a  ptosis  of  one  or  more  of  the 
abdominal  viscera,  with  dragging  on  the  supports  of  the  dia- 
phragm and  a  greater  or  less  derangement  of  the  functions 
of  the  abdominal  organs. 

^  When  the  greater  curvature  of  the  stomach  is  below  the 
navel  it  suggests  either  a  dilatation  of  a  normally  placed 
stomach  or  a  descent  (ptosis)  of  the  whole  organ,  or  a  com- 
bination of  descent  with  a  dilatation.  Mark  this  distinc- 
tion, however,  —  in  the  case  of  dilatation  alone  the  upper 


STOMACH   AND   DUODENUM.  15 

border  of  the  stomach  is  high,  practically  in  its  normal  posi- 
tion, while  in  the  case  of  descent  of  the  whole  organ  both 
greater  and  lesser  curvatures  are  much  below  their  normal 
position. 

^  A  broad  reach  of  gastric  tympany  across  the  abdomen 
indicates  a  dilated  stomach,  not  a  displaced  stomach. 

^  A  tender  and  palpable  right  kidney  commonly  is  as- 
sociated with  descent  of  the  stomach,  the  transverse  colon 
and  other  abdominal  organs. 

^  Such  a  symptom  of  appendicitis  as  tenderness  in  the 
appendix  region  is  extremely  common  in  all  cases  of  ab- 
dominal ptosis,  and  is  common  also  in  many  cases  of  gastric 
disease. 

Our  preliminary  clinical  diagnosis  in  this  case  was  a  non- 
malignant  pyloric  obstruction,  with  dilatation  of  the  stomach, 
associated  probably  with  a  certain  amount  of  general  ab- 
dominal ptosis.  I  operated  and  found  the  stomach  greatly 
dilated,  its  lower  border  lying  about  two  inches  below  the 
umbilicus,  while  there  were  numerous  dense  adhesions  about 
the  pylorus,  holding  that  organ  high  against  the  liver.  There 
was  no  evidence  of  ulcer  in  the  pylorus,  however,  or  in 
the  pyloric  end  of  the  stomach;  that  is  to  say,  there  was 
no  thickening,  nor  were  there  apparent  scars.  There  were 
further  adhesions  between  the  gall  bladder  and  the  transverse 
colon.  Such  adhesions  are  due  usually  to  the  extension  of 
an  old  inflammation,  and  we  looked  for  evidences  of  such 
inflammation  in  the  stomach,  in  the  bile  passages,  and  about 
the  appendix.  I  found  no  sign  of  a  pre-existing  inflammation 
except  the  adhesions,  however,  and  was  at  a  loss  to  account 
for  their  presence,  except  on  the  assumption  that  there  may 
have  been  a  gastric  or  duodenal  ulcer  which  had  healed 
completely.  The  pylorus  was  obstructed,  not  from  an  organic 
thickening  at  that  point,  but  from  a  high  kink  in  the  gut,  due 
to  the  weight  of  the  greatly  distended  stomach  pulling  down 
upon  the  pylorus.  I  have  never  seen  benefit  result  from  break- 
ing up  these  adhesions,  for  they  almost  certainly  form  again. 
Accordingly,  I  performed  the  operation  of  posterior  gastro- 
enterostomy. 

The  patient  recovered  slowly  from  the  operation,  but  by 
the  middle  of  the  third  week  was  sitting  up  and  taking  solid 


1 6  SURGICAL    PROBLEMS. 

food  without  symptoms  of  distress.  Two  weeks  later  her 
appetite  was  excellent  and  her  strength  greatly  improved; 
she  had  begun  to  gain  weight,  and  in  appearance  was  quite  a 
different  person  from  the  wretched  invalid  I  have  described. 
My  last  interview  with  this  patient  was  on  April  4,  1907, 
sixteen  months  after  the  operation,  when  I  made  this  note: 
"  The  patient  reports  in  excellent  general  health,  feels  vigorous, 
and  carries  on  her  work  with  enthusiasm ;  the  constipation  is 
apparently  cured  and  there  are  no  gastric  symptoms.  Patient 
looks  and  feels  very  well." 


STOMACH   AND   DUODENUM.  17 

Case  3.  In  November,  1905,  John  Hadlock,  a  shipmaster, 
brought  to  me  his  daughter,  a  young  woman  of  twenty-four, 
who  had  been  for  some  years  under  the  care  of  a  competent 
internist  and  had  been  treated  for  "  acid  dyspepsia."  One 
could  make  little  of  her  history,  which  was  mainly  negative. 
When  a  child  of  ten  she  seems  to  have  had  an  attack  of  acute 
appendicitis,^  which  subsided  without  an  operation, —  an 
appendicitis  lasting  several  weeks  in  all,  bringing  her  into 
a  condition  of  great  prostration  and  rendering  her  an  invalid 
for  a  year  or  more.  For  many  years  subsequently,  however, 
she  enjoyed  the  vigorous  health  of  a  growing,  active,  country 
girl. 

Both  the  father  and  daughter  laid  great  stress  on  the  fact 
that  some  four  years  before  I  saw  her  she  had  taken  a  voyage 
with  him  to  the  West  Indies,  and  had  there  suffered  for  some 
weeks  with  a  prostrating  malaria.  No  subsequent  ill  effects, 
however,  seem  to  have  persisted. 

Why  had  she  been  under  a  physician's  care  for  the  past 
year  of  more?  Her  only  complaint  was  a  slight  feeling  of 
oppression  after  all  meals, ^  and  occasionally  an  intense  at- 
tack of  that  peculiar  burning  distress  in  the  esophagus  which 
we  have  come  to  call  "  heartburn."^ 

A  physical  examination  revealed  two  interesting  and  often 
associated  conditions, —  a  stomach  with  a  capacity  of  three 
quarts  of  water,  and  an  extremely  tender  and  palpable 
appendix.^  The  stomach  was  not  prolapsed;  the  case  was 
one  of  gastrectasia  or  dilatation.  On  distention  of  the  stomach 
with  air,  the  gastric  tympany  was  found  to  reach  from  the 
left  nipple  to  the  navel,  and  widely  across  the  abdomen. 
There  were  no  other  signs  or  symptoms  of  any  significance. 
The  urine  was  not  abnormal,  and  the  pelvic  organs  were  said 
to  perform  their  functions  in  a  proper  fashion. 

^  A  single  severe  attack  of  appendicitis  may  leave  behind 
it  a  long  train  of  symptoms, —  constipation,  faulty  metabolism, 
nausea,  tenderness  in  various  parts  of  the  abdomen,  malaise, 
small  appetite,  together  with  extensive  adhesions  involving 
many  organs  and  depending  on  the  spread  of  the  peritonitis 
which  was  associated  with  the  appendicitis. 

2  This  sensation  is  due  to  lack  of  proper  digestive  activity, 


1 8  SURGICAL    PROBLEMS. 

and  may  be  occasioned  by  disease  of  the  appendix,  bile 
passages,  liver,  stomach  or  pancreas. 

^  Heartburn  is  commonly  due  to  gastric  fermentation,  and 
not  to  hypochlorhydria,  as  is  frequently  assumed. 

^  A  chronic  appendicitis  may  well  have  caused  all  the  symp- 
toms. 

We  made  a  clinical  diagnosis  of  gastric  dilatation,  due  to 
pyloric  obstruction,  but  we  bore  in  mind  always  the  possibility 
of  a  chronic  appendicitis  as  the  causative  factor  in  the  case. 
I  operated  and  found  a  stomach  dilated,  and  not  prolapsed, 
the  lower  border  being  one  inch  below  the  navel.  The  stomach 
was  deeply  injected  in  the  pyloric  region,  where  there  were  a 
few  slight  adhesions,  the  pylorus  admitting  the  little  finger 
witl>-diificulty.  The  appendix  was  large,  thickened,  adherent, 
injected,  and  contained  two  small  concretions.  In  other  words, 
here  were  two  processes,  a  pyloric  stenosis  and  a  chronic 
appendicitis.  Posterior  gastro-enterostomy  gave  the  stomach 
proper  drainage ;   at  the  same  time  I  removed  the  appendix. 

The  patient  made  an  excellent  convalescence.  Six  weeks 
after  the  operation  she  reported  to  me,  and  looked  vigorous, 
strong  and  rosy.  One  year  later  she  reported  again,  in  perfect 
health. 


STOMACH   AND   DUODENUM.  I9 

Case  4.  Four  years  ago  a  physician  of  forty-eight  consulted 
me  because,  as  he  said,  he  had  heard  me  read  a  paper  on  the 
surgery  of  the  stomach,  and  he  added  the  further  information 
that  his  own  stomach  needed  mending.  He  told  me  a  long 
and  instructive  story.  Some  twenty  years  ago,  when  a  young 
practitioner,  he  had  been  overcome  in  the  street  by  an  agoniz- 
ing attack  of  bellyache,^  and  had  been  carried  to  the  Massachu- 
setts General  Hospital,  where  he  was  kept  under  observation 
for  three  weeks.  During  his  stay  there  he  had  had  two  or 
three  passages  of  blood  from  the  rectum  ^  and  two  or  three 
acute  attacks  of  epigastric  pain,^  relieved  by  morphia  only. 
He  was  treated  for  gastric  ulcer,'*  by  starvation,  by  nutrient 
enemata  and  by  absolute  rest.  At  the  end  of  three  weeks 
he  was  so  far  recovered  as  to  return  to  his  work,  which  he  had 
pursued  vigorously  ever  since. 

This  physician's  further  physical  history,  however,  had 
not  been  unclouded.  Some  three  times  during  the  past  twenty 
years  he  had  had  severe  attacks  of  pain  similar  to  the  one  I 
have  described,  together  with  the  passage  of  blood  from  the 
rectum,  and  twice  associated  with  the  vomiting  of  blood.^ 
He  informed  me  that  there  was  a  constant  feeling  of  weight 
in  the  stomach,  as  though  it  were  full  of  liquid,  and  a  moderate 
sense  of  outward  pressure  after  the  taking  of  food.  He 
stated  further  that  when  not  tired  or  nervous  his  stomach 
emptied  itself  in  six  hours®  of  any  moderate-sized  meal,  and 
that  there  was  no  conscious  fermentation.  At  the  same  time, 
his  bowels  were. regular.  Furthermore,  he  said  that  during  the 
past  six  weeks  there  had  been  a  sense  of  moderate  soreness  ^ 
in  the  epigastrium  and  a  feeling  as  of  a  bunch  or  swelling  at  the 
pylorus,^  over  which  food  was  felt  to  pass,  while  the  epigas- 
tric region  was  always  slightly  tender.  He  was  troubled  also 
by  a  frequent  cough,  without  assignable  cause. ^  The  patient 
asserted  his  conviction  that  there  was  a  gastric  ulcer  in  the 
pyloric  area,^"  and  that  this  ulcer  healed  readily  on  starv'^ation. 
There  had  been  no  hypochlorhydria  for  a  year,  while  he  had 
eaten  ordinary  food,  with  the  exception  of  ripe  fruit,  without 
further  discomfort  than  I  have  described.  He  said  that  he 
was  seldom  hungry,  but  that  a  complete  loss  of  appetite  al- 
ways  preceded   the   formation   of  a   fresh   ulcer.      In   other 


20  SURGICAL    PROBLEMS. 

words,  his  belief  was  that  his  ulcer  came  and  went,  depending 
on  treatment;  that  he  could  produce  an  ulcer  at  will,  and  that 
he  could  cure  it  promptly  by  starvation. 

This  man  seems  to  have  had  a  remarkable  capacity  for 
living  without  food.  Immediately  after  his  first  visit  to  me 
he  retired  to  a  quiet  place  in  the  country,  where  he  lay  in  a 
hammock  for  twenty-one  days,  sustaining  life  by  water  only. 
This  treatment  so  far  allayed  his  gastric  symptoms  that  he 
went  away  to  the  woods  for  a  long  vacation,  but  six  months 
later  returned  to  me  with  the  statement  that  he  was  tired 
of  his  present  mode  of  existence  and  wished  an  exploratory 
operation  on  the  stomach. 

The  striking  features  in  his  case  were  the  ready  yielding 
of  the  disease  to  starvation  treatment,  and  the  patient's 
extraordinary  capacity  for  enduring  such  treatment, —  ex- 
traordinary when  measured  by  average  standards,  for  it  is 
not  improbable  that  most  patients,  if  properly  instructed, 
might  be  enabled,  or  might  be  induced,  to  retain  comparative 
health  by  following  a  similar  plan. 

^  Sudden,  overwhelming  bellyache  may  be  due  to  gall- 
stones, appendicitis,  tubal  rupture  (in  woman),  hemorrhage, 
pancreatitis  and  the  perforation  of  a  gastric  or  duodenal  ulcer. 

^  Blood  from  the  rectum  is  commonly  due  to  hemorrhoids, 
rectal  cancer,  or  hemorrhage  into  the  intestine  high  up, 
as  from  duodenal  ulcer. 

^  The  commonest  cause  of  acute  epigastric  pain  is  gall- 
stones. 

^  We  must  distinguish  acute  gastric  ulcer  from  the  chronic 
form.  Acute  ulcer  is  most  common  in  young  women ;  chronic 
ulcer  is  most  common  in  men  after  thirty.  Acute  ulcer  is 
cured  by  giving  the  stomach  rest;  chronic  ulcer  is  improved, 
but  rarely  cured,  by  the  rest  treatment. 

^  Simultaneous  vomiting  of  blood  and  passing  blood  by  the 
rectum  suggests  a  source  of  hemorrhage  close  to  the  pylorus, 
either  in  the  stomach  or  duodenum, 

®  This  lapse  of  time  indicates  little  or  no  gastric  stasis. 

^  Such  moderate  soreness  suggests  gastritis  or  a  chronic 
gastric  ulcer. 

^  This  sensation  would  probably  not  be  observed  by  a  person 
unfamiliar  with  anatomy. 

^  Such  a  cough  suggests  irritation  of  the  diaphragm. 


STOMACH   AND   DUODENUM.  21 

'"  Three  quarters  of  all  gastric  ulcers  are  in  the  pyloric 
area.  Duodenal  ulcers  near  the  pyloric  sphincter  are  almost 
equally  common  with  gastric  ulcers. 

On  opening  this  patient's  abdomen  I  found  extensive,  tough 
adhesions  matting  the  gastrohepatic  omentum,  the  duodenum, 
the  pylorus,  the  liver  and  the  anterior  abdominal  wall. 
I  separated  the  anterior  adhesions,  but  was  careful  not  to 
break  up  the  adhesions  between  the  pylorus  and  the  liver, 
in  order  to  avoid  possible  hemorrhage  and  a  biliary  fistula, 
with  the  thought  in  mind  also  that  a  posterior  perforating 
duodenal  ulcer  might  lie  outside  of  the  peritoneum.  These 
dense  pylorohepatic  adhesions  held  the  duodenum  high 
and  kinked.  The  pylorus  admitted  a  little  finger  tip  with 
difficulty.  There  were  dense,  thick  scars  the  size  of  a  silver 
dollar  in  the  posterior  duodenal  wall,  two  inches  from  the 
pylorus.  The  stomach  was  distended  with  gas,  its  lower  bor- 
der about  two  fingers'  breadth  below  the  navel.  There  was  no 
sign  of  disease  in  the  stomach  itself;  there  was  no  evidence 
of  disease  of  the  bile  passages;  the  pancreas  did  not  appear 
abnormal.  I  performed  posterior  gastro-enterostomy,  though 
I  would  have  been  glad  to  do  a  pyloroplasty  by  Finney's 
method  had  the  duodenum  been  normally  movable. 

Thirteen  days  after  the  operation  this  physician  stated  that 
he  felt  greatly  improved,  and  described  a  feeling  of  freedom 
and  ease  in  his  epigastrium.  Fifteen  days  after  the  operation 
he  went  away  to  his  summer  camp.  In  the  four  years  since 
the  operation  he  has  had  no  digestive  disturbances. 


22  SURGICAL    PROBLEMS. 

Case  5.  Frank  Ridlon  was  operated  on  by  me  at  the  Mas- 
sachusetts General  Hospital  in  July,  1906.  This  unfortunate 
man  was  thirty-six  years  old  when  he  went  to  the  hospital. 
He  had  led  the  active,  vigorous,  alcoholic  life  of  a  lumberman. 
For  four  years  he  had  suffered  from  increasing  gastric  dis- 
turbance, and  had  the  characteristic  symptom  of  dilatation 
of  the  stomach,  —  the  vomiting  of  enormous  quantities  of 
food  two  or  three  times  a  week. 

I  performed  a  posterior  gastro-enterostomy  on  this  patient, 
though,  as  subsequent  events  demonstrated,  I  might  better 
have  done  a  pyloroplasty,  giving  the  stomach  free  drainage 
directly  into  the  duodenum.  The  man's  stomach  was  greatly 
distended,  the  lower  border  being  four  inches  below  the  navel, 
and  his  jejunum  showed  an  abnormality,  interesting  to  anato- 
mists and  to  surgeons:  the  ligament  of  Treitz,  that  fold 
which  separates  the  duodenum  from  the  jejunum,  was  found 
to  be  unusually  placed,  so  that  the  jejunum,  instead  of  spring- 
ing from  the  left  side  of  the  spinal  column  was  found  to  spring 
from  the  right  side  of  the  spinal  column.  This  fact  struck  me 
as  interesting,  but  its  significance  and  its  bearing  upon  the 
operation  of  posterior  gastro-enterostomy  did  not  occur  to 
me  at  the  time.  The  gastro-enterostomy  was  done  with  a  short 
loop,  making  the  length  of  the  jejunal  limb  four  inches  from 
ligament  of  Treitz  to  the  stoma  in  the  stomach. 

The  next  day  the  patient  felt  unusually  well;  he  was  free 
from  nausea  and  pain,  took  water  and  broths  readily,  and 
found  his  appetite  returning.  This  satisfactory  condition 
lasted  four  days,  when  I  regarded  him  as  cured.  On  the  even- 
ing of  the  fifth  day,  however,  he  was  seized  suddenly  with 
agonizing  pain  in  the  epigastrium;  he  collapsed;  his  pulse 
went  quickly  to  160;  his  temperature  fell  to  96;  he  became 
cold  and  clammy  and  presented  all  the  evidences  of  dissolu- 
tion ;  stimulants  failed  to  help  him ;  he  remained  in  collapse 
for  some  twelve  hours  and  then  died. 

The  unforeseen  calamity  puzzled  me  exceedingly.  The 
autopsy  revealed  an  extremely  interesting  situation;  the  short 
four-inch  loop  of  jejunum  proximal  to  the  stoma  was  found 
drawn  very  tense,  and  the  jejunum  itself  was  almost  com- 
pletely torn  off  from  the  stomach,  so  that  the  stomach  con- 


STOMACH   AND   DUODENUM. 


23 


tents  had  poured  out  into  and  filled  the  abdominal  cavity. 
The  patient  died  of  the  shock. 

After  I  had  published  the  case  some  months  later,  I  was 
interested  to  find  that  the  significance  of  this  arrangement 
had  not  then  occurred  to  other  surgeons. 

We  explain  the  autopsy  findings  as  follows.  The  short 
four-inch  jejunal  loop  at  operation  had  been  attached  easily 
to  a  low  pyloric  portion  of  the  greatly  dilated  stomach. 
With  the  consequent  relief  to  pyloric  obstruction,  the  cause 
of  the  stomach's  dilatation  was  removed,  and  that  organ  pro- 
ceeded to  contract  back  into  its  normal  position  and  dimen- 
sions. As  it  contracted,  it  drew  up  with  it  the  jejunal  loop, 
and  that  loop,  springing  as  it  did  from  the  right  side  of  the 
spinal  column  and  not  from  the  left  side,  proved  to^  be  too 
short.  Had  it  sprung  from  the  left  side  it  would  still  have 
accommodated  the  contracting  stomach.  As  it  was,  the  stoma 
was  drawn  so  far  over  to  the  left  that  it  dragged  unduly 
upon  the  proximal  loop,  so  that  there  resulted  the  fatal  acci- 
dent which  I  have  described. 


Dilated  stomach.    Pyloric  adhesions.    (Author's  Dilated  stomach.     Pyloric  adhesions.     Gastro- 

c&%^,  Annals  of  Surgery .)  .  enterostomy.  Stomach  partly  retracted.   (Author's 

case,  Annals  0/ Surgery.) 


24  SURGICAL    PROBLEMS. 

Case  6.  Peter  Smith,  a  shriveled  and  neurotic  farmer, 
consulted  me  for  indigestion,  in  the  autumn  of  1909.  He  was 
forty-eight  years  old,  and  said  that  he  had  been  a  dyspeptic 
for  ten  years. ^  Seven  years  before  I  saw  him  he  had  had  a 
severe  attack  of  general  abdominal  pain,  which  passed  off 
without  special  treatment^;  but  always  since  then,  after  slight 
exertion  or  excess  in  eating,  he  had  felt  gastric  distress  and 
as  though  there  were  a  load  on  his  stomach.^  He  had  chronic 
constipation.  Two  days  before  I  saw  him  he  had  a  severe 
attack  of  pain  in  the  epigastrium,^  which  gradually  shifted 
around  to  the  right,  following  the  border  of  the  ribs,  along 
no  definite  anatomical  line.  He  was  relieved  by  rest  and  the 
drinking  of  hot  water,  but  still  a  slight  pain  persisted,  begin- 
ning in  front,  about  three  inches  above  the  navel,  and  following 
the  course  of  the  ribs.^  His  chest  and  urine  were  not  abnormal. 
There  were  no  other  symptoms. 

Mr.  Smith  was  a  short,  slight  man,  weighing  one  hundred 
and  thirty-eight  pounds,  and  anxious  looking.  His  abdomen 
was  not  peculiar,  and  nowhere  could  I  discover  pain  or  tender- 
ness except  at  a  point  in  the  middle  line  two  inches  below  the 
xiphoid  cartilage,*'  where  there  was  marked  tenderness  on 
pressure.  Nowhere  else  in  the  abdomen  were  there  any  signs 
whatever.  This  man's  age  and  the  long  continuance  of  the 
disorder  led  me  to  suspect  cancer  of  the  stomach.  An  analysis 
of  the  stomach  contents  seemed  to  confirm  my  suspicion ;  the 
stomach  was  not  dilated ;  there  was  no  free  acid  from  the  fast- 
ing stomach ;  the  guaiac  test  was  positive  of  hemorrhage ;  there 
were  a  few  Oppler-Boas  bacilli,  with  a  few  blood  corpuscles 
and  occasional  squamous  cells. 

A  teaspoonful  of  bright  blood  followed  the  withdrawal  of 
the  tube.  After  an  Ewald  meal  there  was  a  total  free  hydro- 
chloric acid  0.014  P^r  cent,  with  a  total  acidity  0.13  per  cent. 
This  examination  suggested  that  the  trouble  was  in  the  fundus 
rather  than  at  the  pyloric  end  of  the  stomach. 

^  The  symptoms  in  this  case  are  extremely  confusing  and 
point  to  a  variety  of  organs.  A  long-continued  dyspepsia 
of  the  kind  suggests  especially  chronic  duodenal  ulcer. 

^  One  remote  attack  of  pain  of  this  nature  suggests  especially 
acute  appendicitis. 


STOMACH  AND   DUODENUM.  25 

^  This  symptom  again  suggests  duodenal  ulcer,  with  pyloric 
obstruction. 

■*  Such  an  attack  of  pain  as  he  described  pointed  to  perfora- 
ting peptic  ulcer,  or  gallstones,  or  acute  pancreatitis,  or  gastro- 
mesenteric  ileus  as  probable. 

'^  This  meaningless  course  of  the  pain,  taken  together 
with  the  patient's  general  appearance  and  temperament, 
suggested  a  neurotic  state  without  anatomical  foundation. 

*^  The  location  of  the  pain  in  the  epigastrium  pointed  again 
to  ulcer  or  cancer  of  the  stomach,  to  gallstones  or  to  pan- 
creatitis. 

Abdominal  section  revealed  the  following  interesting  facts: 
all  the  upper  portion  of  the  abdomen  was  found  free  from 
adhesions  of  any  sort;  the  stomach  was  normal  in  size  and 
position,  and  the  palpating  hand  revealed  no  abnormalities 
whatever;  there  was  no  thickening  anywhere,  no  scars,  no 
enlarged  lymph-nodes;  the  stomach  was  pale,  rather  than 
the  reverse;  the  pancreas  was  not  peculiar  to  the  touch;  the 
bile  passages  were  free  from  disease ;  the  pylorus  and  duode- 
num presented  no  abnormal  features ;  the  intestines  were  pale 
and  empty.  The  appendix,  however,  showed  marked  evidence 
of  a  long- time  disturbance;  it  was  thickened,  segmented  at 
the  tip,  and  closely  adherent  to  the  colon  and  to  the  side  of 
the  pelvis.    I  removed  the  appendix  and  closed  the  wound. 

The  patient  made  an  excellent  convalescence.  On  the 
fourth  day  his  appetite  returned  and  his  diet  was  increased. 
He  left  the  hospital  on  the  eleventh  day,  and  two  weeks  later 
came  to  see  me,  reporting  that  he  felt  well.  Six  months  after 
the  operation  he  wrote  me  that  he  was  well,  and  able  to  do 
a  full  day's  work  without  discomfort,  while  his  weight  was 
steadily  increasing. 


26  SURGICAL    PROBLEMS. 

Case  7.  On  the  ist  of  April,  19 10,  I  went  to  a  remote 
village  in  Maine,  at  the  call  of  a  consultant,  to  operate  on  a 
middle-aged  farmer  who  had  long  been  the  victim  of  a  serious 
stomach  ailment.  The  patient,  Alfred  Gorham,  was  fifty-six 
years  of  age.  For  two  years,  or  possibly  longer,  he  had  suffered 
from  increasing  digestive  disturbances,  with  eructations, 
constipation,  occasional  nausea.  He  had  lost  fifty  pounds. 
He  had  consulted  numerous  physicians,  and  a  year  before  I 
saw  him  had  been  advised  that  he  could  live  but  a  few  weeks. 
His  unusual  vigor  and  force  of  character  apparently  combined 
to  carry  him  along. 

My  examination  of  this  man  showed  him  to  be  considerably 
emaciated,  pallid  and  cachectic,  though  his  frame  was  large 
and  his  heart  action  vigorous.  Beneath  the  parchmentlike 
and  retracted  skin  of  his  abdomen  I  felt  readily  a  mass  the 
size  of  a  man's  fist,  situated  in  the  middle  of  the  epigastrium. 
I  was  obliged  to  confirm  the  obvious  and  inevitable  diagnosis 
of  cancer  of  the  stomach  which  had  been  made  before  by  his 
other  physicians,  but  I  was  presented  with  one  of  those  serious 
problems  of  treatment  which  every  surgeon  must  face  from 
time  to  time.  The  man  was  starving,  and  was  in  misery  with 
thirst  and  an  unsatisfied  hunger.  He  begged  me  to  attempt 
an  operation  for  his  relief,  even  though  the  operation  should 
prove  fatal. 

I  operated  and  found  a  familiar,  characteristic  condition 
within  the  abdomen.  The  whole  pyloric  area  of  the  stomach 
was  involved  in  cancer;  the  pylorus  was  choked,  the  trans- 
verse colon,  gall  bladder  and  omentum  were  invaded  by  the 
disease,  and  extensive  cancerous  nodes  filled  the  gastrohepa- 
tic  omentum;  the  stomach  was  tied  down  posteriorly  to  the 
pancreas. 

I  performed  rapidly  and  satisfactorily  an  anterior  gastro- 
enterostomy, with  a  long  loop.  The  time  consumed  in  the 
operation  was  short,  and  the  patient  was  put  to  bed  in  fair 
condition.  The  next  morning  I  received  the  following  note 
from  his  physician:  "  I  regret  to  inform  you  that  our  patient, 
Mr.  Gorham,  never  rallied  from  the  shock,  and  died  at  2  a.m. 
to-day." 

I  report  this  rather  commonplace  case  because  it  may  help 


STOMACH   AND   DUODENUM.  2/ 

to  answer  the  question  which  a  family  physician  so  often  asks 
himself, —  a  question  which  is  frequently  presented  to  the 
operating  surgeon  also, —  Is  a  palliative  operation  in  advanced 
cancer  of  the  stomach  ever  permissible?  I  believe  that  it  is  so. 
I  have  nothing  to  regret  in  connection  with  the  case  of  Mr. 
Gorham.  There  were  two  possible  outcomes  of  the  operation, 
and  these  outcomes  were  carefully  explained  to  the  patient 
and  to  his  family:  he  might  never  rally  from  his  anesthetic, 
and  in  that  case  would  experience  euthanasia;  or  he  might 
rally  and  live  many  weeks  in  a  condition  of  comfort  vastly 
different  from  the  misery  of  the  previous  six  months. 


ACUTE   INFECTION. 

Case  8.  Some  ten  years  ago  Eliot  Sears,  a  man  of  forty- 
five,  came  into  my  office,  with  an  apology  for  his  trifling 
errand,  and  showed  me  beneath  his  mustache,  on  the  left 
side,  near  the  middle  line,  a  slight  pustule  which  was  giving 
him  some  annoyance. 

This  man  was  of  a  distinctly  neurotic  type,  and  had  retired 
from  business  a  year  before  because  he  found  himself  unable 
to  stand  the  strain  of  a  confining  and  anxious  office  life.  His 
previous  history  was  in  no  way  remarkable,  except  that  on  two 
occasions  he  had  suffered  severely  from  a  sub-deltoid  bursitis. 
In  other  respects  at  the  time  of  his  visit  to  me  he  was  sound, 
and  had  passed  a  healthful  and  vigorous  year  in  out-of-doors 
life. 

On  examining  his  upper  lip  I  could  find  nothing  but  the 
trifling  pustule  ^  of  which  he  told,  a  lesion  about  as  large  as 
the  head  of  a  small  pin,  with  a  very  slight  reddened  aureola 
about  it.  I  opened  it,  gave  him  an  alcohol  wash,  and  telling 
him  to  let  me  know  if  he  was  not  comfortable  on  the  following 
day,  I  sent  him  off  expecting  to  hear  nothing  more  from  him. 

The  next  morning,  about  four  o'clock,  I  was  summoned  to 
his  house,  and  found  him  pacing  the  floor  in  great  distress, 
apparently  mental,  professedly  physical.  He  pointed  to  his 
lip  and  intimated  that  he  was  unable  to  speak.  On  examining 
the  lip  this  second  time  I  found  it  considerably  swollen  and 
indurated  about  the  site  of  the  little  pustule,  which  had  now 
taken  on  the  appearance  of  a  small  boil.^  It  was  about  the 
size  of  a  gold  dollar,  red,  elevated,  indurated,  with  a  crater, 
from  the  center  of  which  a  drop  of  pus  could  be  squeezed. 
The  culture  taken  later  showed  the  organism  to  be  staphy- 
lococcus aureus.  Besides  his  swelling  of  the  lip,  the  patient 
exhibited  a  cheek  which  was  becoming  tense  and  shiny,  while 
his  eye  was  partially  closed  by  the  swelling.  His  pulse  was 
90,  his  temperature  100°.  The  condition  was  distinctly 
alarming  to  Mr.  Sears,  and  gave  me  at  once  a  feeling  of  con- 

29 


30  SURGICAL    PROBLEMS. 

siderable  apprehension.  I  explained  to  him  the  nature  of  the 
affliction  ^  which  had  befallen  him,  and  advised  his  taking 
an  anesthetic  and  having  an  immediate  operation. 

^  Infections  of  the  upper  lip  are  rare,  but  when  present 
are  often  persistent,  and  are  liable  to  spread  rapidly  on  account 
of  the  extreme  vascularity  and  abundant  lymphatic  connec- 
tions of  the  lips  and  face. 

^  So  virulent  an  infection  as  I  have  described  here  must 
be  met  with  our  most  active  measures ;  no  halfway  treatment 
will  suffice.  One  may  not  say  whether  the  lesion  at  this  stage 
was  a  small  boil  or  a  carbuncle.  The  distinction  is  not  always 
obvious,  but  the  only  safe  treatment  is  a  rapid  and  thorough 
excision.  Sometimes  deep  crucial  incisions  will  suffice,  but 
they  are  less  effective,  because  they  fail  to  remove  the  cause 
of  the  infection  and  provide  efficient  drainage. 

^  A  patient  suffering  from  carbuncle  of  the  upper  lip  must 
be  handled  vigorously,  and  must  be  made  to  understand 
thoroughly  the  urgency  of  his  case.  Carbuncle  of  the  upper 
lip  is  far  the  most  dangerous  form  of  carbuncle.  Many 
patients  die  of  it.  The  infection  spreads  rapidly,  causing 
a  septic  phlebitis  which  involves  the  facial  vein,  the  veins 
of  the  orbit,  and  so  the  cavernous  sinus,  with  a  resulting 
septic  meningitis  and  death,  the  whole  course  of  the  disease 
being  but  a  few  days.  To-day,  with  opsonic  vaccines  at 
our  command,  the  surgeon  is*  justified  in  attempting  to 
abort  the  carbuncle  by  simple  incisions  and  the  injection 
of  autogenous  vaccines,  that  is,  provided  he  sees  the  case  in 
its  earliest  stages.  Such  a  case  as  I  have  here  described,  how- 
ever, must  be  treated  at  once  by  excision,  and  the  vaccines 
given  later,  if  at  all. 

I  was  obliged  to  shave  the  patient's  mustache,  an  operation 
which  seemed  to  mortify  him  extremely.  I  then  administered 
ether  and  excised  cleanly  the  inflamed  area,  taking  out  a  cone 
of  disorganized  tissue,  with  the  base  as  large  as  a  little 
fingernail  and  the  tip  reaching  nearly  to  the  mucosa  on  the 
inner  side  of  the  lip.  His  temperature  fell  to  normal  during 
the  day,  his  pain  subsided  almost  instantly,  and  before  the 
mustache  had  grown  an  inch  the  wound  had  cicatrized. 

This  is  an  admirable  example  of  the  efficacy  of  prompt 
dealing  with  carbuncle  of  the  lip. 


■     "SEIZURES." 

Case  9.  On  the  17th  of  August,  1906,  Mrs.  R.  P.  Cornice 
consulted  me  regarding  her  daughter,  a  vigorous,  athletic 
girl  of  eighteen.  The  patient  had  suffered  from  none  of  the 
ordinary  children's  diseases,  and  until  the  age  of  sixteen  had 
been  well,  except  for  some  intestinal  disorder  at  the  age  of  ten, 
a  disorder  which  was  not  apparent  when  I  saw  her.  Further, 
at  the  age  of  fifteen  she  had  had  a  disturbing  mucous  colitis,^ 
which  lasted  about  six  months.  In  spite  of  these  illnesses, 
however,  she  had  been  able  to  go  to  school,  and  was  well 
developed,  physically  and  mentally.  For  the  two  years 
preceding  her  eighteenth  year,  however,  she  had  been  suffering 
from  increasingly  frequent  epileptiform  convulsions,^  as  they 
were  described  to  me  by  her  mother, —  general  convulsions, 
coming  on  at  first  once  a  month  and  now  seizing  her  every  five 
or  ten  days,  convulsions  not  marked  by  the  activity  of  any 
special  set  of  muscles,  and  generally  appearing  at  night. 
Her  mother  spoke  of  them  as  causing  loss  of  consciousness, 
flushing  of  the  face,  clinching  of  the  jaws,  occasional  biting 
of  the  tongue,  and  rigidity  and  spasms  of  the  trunk,  legs  and 
arms.  They  would  last  anywhere  from  five  minutes  to  half 
an  hour,  and  were  obviously  of  the  familiar  so-called  idio- 
pathic type.  The  mother  assured  me  that  the  family  history 
pointed  to  nothing  which  threw  light  on  her  daughter's  con- 
dition. She  was  convinced,  however,  that  the  seizures  were 
due  to  some  internal  derangement,  and  begged  me  to  make 
a  thorough  examination  of  the  girl,  especially  of  her  pelvic 
organs. 

I  consulted  a  well-known  neurologist  the  next  day,  and  with 
his  cooperation  made  a  careful  examination  of  the  patient. 
She  was,  as  described,  well  grown,  of  good  color,  in  good  flesh, 
ruddy  and  intelligent.  She  professed  to  have  little  knowledge 
herself  of  the  time  or  nature  of  her  seizures.  There  was  no 
history  to  be  obtained  of  injury  to  the  head;  the  chest  was 
negative,  and  the  abdomen  was  negative  as  far  down  as  the 

31 


32  SURGICAL    PROBLEMS. 

pelvis.  The  pelvic  organs,  however,  showed  certain  abnor- 
malities. The  uterus,  while  of  good  size,  was  retroverted  in 
the  third  degree,  and  on  the  right  side  there  was  felt  a  small 
tumor,  corresponding  to  the  position  of  the  right  ovary, 
a  tumor  cystic  to  the  feel  and  about  the  size  of  a  small  lemon. 
This  examination  of  the  pelvis  was  made  with  the  patient 
anesthetized.^ 

^  We  are  accustomed,  justly  or  unjustly,  to  associate  the 
term  "  mucous  colitis  "  with  a  neurotic  state  —  with  a  dis- 
turbed psychic  equilibrium.  Our  present  knowledge  of  vis- 
ceral ptosis,  however,  should  lead  us  generally  to  expect  a 
descent  of  the  large  intestine  in  cases  of  mucous  colitis.  Vis- 
ceral ptosis  in  its  turn  is  a  common  cause  of  disturbed  metabo- 
lism, associated  with  an  abnormal  psychic  state. 

^  Epileptiform  convulsions  coming  on  in  a  vigorous  young 
woman  suggest  often  a  reflex  cause  for  the  convulsions.  The 
serious  idiopathic  epilepsy  develops  usually  in  childhood. 
Convulsions  of  a  reflex  origin  may  be  due  to  any  irritant, 
from  an  ingrowing  toenail  to  a  pyloric  obstruction,  and 
warrant  the  most  careful  and  thorough  investigation.  In 
young  women,  especially,  the  physician  should  examine  care- 
fully the  pelvic  organs. 

^  The  painstaking  physician,  when  examining  the  pelvic 
organs  of  a  young  girl,  will  find  it  both  humane  and  clinically 
advantageous  to  anesthetize  his  patient. 

A  week  later  I  operated  on  this  patient  by  the  trans- 
verse, or  Pfannensteil,  incision,  and  found  the  conditions 
I  have  already  described.  The  uterus  was  extremely  retro- 
verted and  there  was  a  cystic  right  ovary  about  the  size  of  a 
lemon.  I  suspended  the  uterus  by  stitching  the  round  liga- 
ments over  the  recti  muscles,  and  I  removed  the  right  ovary. 

No  psychic  disturbances  whatever  followed  the  operation 
immediately,  and  the  patient  made  a  perfect  and  satisfactory 
recovery,  without  the  slightest  evidence  of  twitching  or 
convulsions  during  her  two-weeks'  stay  at  the  hospital. 
Sixteen  days  after  the  operation  I  made  this  note:  "  No 
symptoms  since  the  operation."  Twenty  days  after  the  opera- 
tion there  was  reported  a  night  terror,  which  may  or  may  not 
have  been  associated  with  her  convulsions.  Two  months 
later  the  mother  called  on  me  and  described  two  extremely 


SEIZURES.  33 

slight  night  attacks,  but  informed  me  that  they  were  insignifi- 
cant, as  compared  with  her  previous  attaclcs,  and  were  far 
apart;  that  is  to  say,  during  the  six  weeks  following  the  oper- 
ation there  had  been  three  questionable  attacks,  all  of  them 
slight  and  well  distributed.  On  the  31st  of  August,  1910, 
her  mother  sent  me  a  report  stating  that  her  daughter  "  is 
much  better,  but  not  entirely  well.  Many  of  the  symptoms 
have  utterly  disappeared,  and  the  doctor  assures  us  that 
she  will  be  absolutely  well.  I  see  a  great  improvement,  and 
cannot  but  feel  greatly  encouraged  and  happy  in  regard  to 
her." 


34  SURGICAL    PROBLEMS. 

Case  10.  On  November  7,  1907,  a  physician  in  the 
neighboring  town  of  Morton  sent  to  me  Miss  Cutler,  a  young 
girl  of  eighteen,  for  diagnosis.  The  patient's  mother  informed 
me  that  she  and  her  physician  were  becoming  increasingly 
anxious  about  the  girl's  health,  because  she  was  subject  to 
severe  headaches  and  dizzy  spells.^  I  found  it  difficult  to 
obtain  a  description  of  these  dizzy  spells.  They  occurred 
frequently  at  night,  and  were  said  to  be  so  severe  that  the 
patient  would  fall  out  of  bed.  Her  mother  thought  that  some- 
times she  was  temporarily  unconscious.  On  one  or  two 
occasions  she  had  observed  twitching  of  the  lids,  rolling  of  the 
eyeballs  and  stiffening  of  both  arms.  These  '^spells"  had  been 
infrequent,  the  last  one  six  months  before  I  saw  the  patient. 
Her  general  mental  condition,  however,  was  unsatisfactory. 
On  cross-questioning  the  mother,  I  learned  that  the  daughter 
was  growing  increasingly  backward  in  her  studies,  finding  it 
difficult  to  keep  up  with  girls  two  and  three  years  her  junior; 
her  memory  was  somewhat  impaired,  and  her  interest  in  the 
usual  amusements  of  her  age  was  slight. 

I  found  Miss  Cutler  to  be  a  dull,  heavy-looking  girl,^ 
appearing  somewhat  older  than  her  given  age.  She  answered 
direct  questions  slowly  and  cautiously,  with  a  heavy  smile, 
and  appeared  to  take  little  interest  in  her  visit  to  my  office 
and  in  her  own  condition. 

Her  mother  informed  me  that  up  to  the  age  of  thirteen 
her  daughter  had  been  a  normal,  vigorous  child.  At  that 
time  catamenia  was  established.  The  flowing  had  always 
been  irregular  and  infrequent,  sometimes  the  periods  skipping 
five,  six  and  seven  months.  The  family  physician  informed 
me  that  they  were  anxious  about  the  girl's  mental  state,  that 
they  feared  a  possible  epilepsy,  the  fear  being  strengthened 
by  the  fact  that  her  father  had  been  a  chronic  alcoholic  and 
had  at  one  time  been  confined  in  an  insane  hospital.  The 
question  presented  to  me  was,  —  Is  this  patient  physically 
normal  ? 

I  made  a  careful  physical  examination,  and  found  little 
that  appeared  wrong.  The  thoracic  organs  were  not  peculiar; 
the  digestive  apparatus  seemed  healthy;  but  the  pelvic 
organs  were  slightly  abnormal.     There  was  a  considerable 


SEIZURES.  35 

excoriation  about  the  vulva,  as  though  the  patient  was 
addicted  to  masturbation,  and  she  admitted  that  she  fre- 
quently scratched  and  rubbed  the  parts.  The  introitus  was 
loose,  the  vagina  flaccid,  the  uterus  rather  small  and  movable 
and  retroverted  in  the  second  degree,  the  cervix  thin  and 
soft  and  the  os  unusually  small.  The  rectum  was  loaded 
with  hard  masses,  and  the  patient  informed  me  that  she  was 
a  victim  to  constipation  and  was  troubled  some  with  a 
leucorrhea. 

My  judgment  at  that  time  led  me  to  try  palliative  measures 
to  improve  the  girl's  general  cort'dition,  and  our  success  in 
these  measures  was  considerable.  Proper  exercises,  laxatives 
and  a  long  course  of  massage  improved  the  bowel  action,^ 
and  the  companionship  of  an  intelligent  nurse  broke  the  girl 
of  her  habit  of  masturbation.  For  more  than  a  year  her 
condition  improved,  and  we  began  to  feel  that  the  improve- 
ment was  permanent.  In  January,  1909,  however,  her 
mother  came  to  me  in  great  anxiety,  and  told  me  that 
her  daughter  had  again  become  subject  to  the  ill-defined  seiz- 
ures which  I  have  described,  and  begged  me  to  attempt  any 
operation  which  I  thought  would  benefit  her  condition. 

^  Dizzy  spells  of  the  sort  suggested  may  be  due  to  a  great 
variety  of  causes,  and  in  young  girls  are  most  commonly 
due  to  menstrual  or  digestive  disturbances. 

2  This  mental  deterioration,  combined  with  the  indefinite 
history  of  loss  of  consciousness  and  "  dizzy  spells,"  must 
be  viewed  with  grave  suspicion,  and  the  thought  in  her 
physician's  mind,  coupled  with  her  father's  insanity,  should 
lead  us  to  regard  the  attacks  as  probably  of  an  epileptic 
nature.  With  this  case  again,  as  with  Case  9,  however, 
we  are  somewhat  comforted  by  the  fact  that  the  attacks  made 
their  first  appearance  after  puberty,  that  up  to  the  age  of 
thirteen  the  patient  was  well  and  vigorous.  With  this  fact 
in  mind,  one  should  not  jump  at  once  to  a  diagnosis,  of  con- 
firmed idiopathic  epilepsy,  but  should  consider  seriously  the 
probability  of  epilepsy  of  the  reflex  type.  Every  physician 
knows,  however,  that  the  parents  of  an  epileptic  child  look 
for  some  irritant  as  a  reflex  cause.  We  should  not  be  misled 
by  the  biased  statements  of  parents  in  reaching  a  diagnosis. 

^  These  measures  obviously  are  directed  to  the  possible 
reflex  cause  of  the  seizures;    and  the  temporary  but  long- 


36  SURGICAL    PROBLEMS. 

continued  improvement  which  resulted  tended  to  confirm 
our  first  feeling  that  the  cause  of  the  seizures  was  reflex. 
Long  subsequently  I  learned  in  a  discussion  of  the  case  with 
the  patient's  mother  that  a  disturbing  and  agitating  love 
affair  may  have  had  much  to  do  with  bringing  on  a  recurrence 
of  the  seizures. 

On  January  28,  1909,  I  operated  on  the  patient.  I  found 
the  pelvic  organs  about  as  I  have  described  them.  The  uterus 
was  small  and  slightly  retroverted,  the  cervix  long  and 
tapering,  the  os  extremely  narrow,  both  ovaries  were  small, 
though  the  condition  can  scarcely  be  described  as  infantile. 
I  dilated  thoroughly  the  cervix,  and  stitched  into  the  os  a 
medium-sized  glass  tube,  which  reached  beyond  the  internal 
OS  and  was  left  in  that  position  for  two  months.  I  dilated  the 
sphincter  ani  also,  with  the  purpose  of  improving  the  consti- 
pated habit. 

Eight  days  after  the  operation  the  patient  went  home  feeling 
well.  During  the  following  five  months  her  menstrual  con- 
dition improved  greatly,  for  she  had  four  periods  during  that 
time.  The  state  of  the  bowels  also  was  satisfactory  and  did 
not  call  for  the  use  of  cathartics.  Six  months  later  I  learned 
by  letter  from  the  patient's  mother  that  the  catamenial 
periods  seemed  to  be  normal  and  regularly  continued,  that 
she  had  had  no  more  "  seizures,"  that  her  mental  condition 
was  greatly  improved  and  that  she  appeared  bright,  alert, 
interested  and  like  a  normal  girl  of  her  years. 


EXPLORATORY  LAPAROTOMY. 

Case  II.  On  the  26th  of  October,  1900,  Mr.  Henry  Lemoyne, 
a  man  of  forty-four,  and  a  Bostonian,  but  for  the  two  pre- 
vious years  resident  in  Cuba,  consulted  me,  with  the  story 
that  he  had  had  a  "  spell  of  fever  "  six  months  before  while 
in  Cuba,  but  that  he  had  thought  no  more  of  it  until  within 
the  past  thirty-six  hours,  during  which  hours  he  had  passed 
bloody  urine  ^  twice  and  had  experienced  a  dull  pain  in  the 
pelvis  and  left  loin.  He  informed  me  further  that  he  was 
obliged  to  return  to  Cuba  on  the  following  day.  He  recognized 
no  other  symptoms,  and  stated  that  he  led  an  active  life  as 
a  planter. 

When  I  saw  him  his  appetite  was  good,  his  bowels  regular 
and  his  appearance  that  of  a  vigorous  though  somewhat 
tired  man.  A  physical  examination  revealed  nothing  of  any 
great  importance.  There  was  a  considerable  varicocele  on  the 
left,  and  a  catheter  specimen  of  urine  showed  macroscopic 
blood;  the  urine  had  a  specific  gravity  of  1028,  it  was  neutral, 
contained  about  one  per  cent  of  albumen,  and  a  dark  reddish 
sediment,  in  which  were  numerous  red  blood  disks,  with  a 
granular  detritus;  there  was  an  abundance  of  urates  but  no 
epithelium  was  found.  An  examination  of  the  blood  showed 
no  malarial  organisms. 

In  view  of  Mr.  Lemoyne's  residence  in  the  tropics,  and  his 
history  of  malarial  fever,  I  made  a  diagnosis  of  malarial 
hematuria,  a  rather  frequent  condition  in  the  West  Indies. 
He  went  back  to  Cuba  the  next  day,  with  directions  regarding 
his  diet  and  the  use  of  quinine.  Five  months  later  I  saw  him 
again  in  Boston.  His  health  was  somewhat  better,  though 
he  had  had  two  slight  hemorrhages  "  from  the  bladder  " 
in  the  interval.  I  examined  him  with  great  care  on  this  occa- 
sion, and  found  a  tumor  in  the  left  hypochondrium, —  a 
tumor  about  the  size  of  a  man's  fist,  movable  and  protruding 
from  under  the  ribs  about  four  inches  below  the  costal  margin. 
I  took  this  to  be  an  enlarged  spleen,  and  conducted  the  case 

37 


38  SURGICAL    PROBLEMS. 

with  this  understanding,  and  on  the  basis  of  chronic  malaria, 
for  several  months.  By  the  middle  of  May  the  tumor  had 
diminished  one  half  in  size,  and  the  patient  had  gained  five 
pounds  and  was  feeling  very  well.  Dr.  Osier  saw  him  with 
me  about  the  middle  of  June,  and  was  inclined  to  believe  the 
tumor  to  be  of  the  kidney,  rather  than  of  the  spleen,  though 
his  conviction  was  not  final  on  that  point.  Within  the  next 
two  weeks  Dr.  A.  T.  Cabot  saw  the  patient  also,  and  agreed 
with  me  that  the  tumor  was  probably  splenic.  The  blood 
examination  was  not  at  all  definite,  and  threw  little  light 
on  the  diagnosis.  Dr.  Cabot  agreed  with  me  that  an  operation 
was  inadvisable,  although  Dr.  Osier  had  suggested  the  wisdom 
of  an  exploration.  The  usual  maneuver  of  blowing  up  the 
colon  with  air  ^  gave  us  surprisingly  little  help  in  arriving 
at  a  diagnosis.  The  distended  colon  appeared  to  lie  behind 
the  tumor  and  to  push  it  upward  and  inward. 

After  the  patient  had  had  three  more  months  of  continual 
anti-malarial  treatment  his  tumor  was  distinctly  smaller 
and  he  felt  greatly  better.  By  the  4th  of  October,  however, 
one  year  after  Mr.  Lemoyne's  first  consultation  with  me,  it 
became  apparent  that  his  progress  was  not  satisfactory;  the 
tumor  still  persisted,  there  were  occasional  hemorrhages,  and 
the  patient's  general  condition  had  been  deteriorating  for 
six  weeks.  Further  consultations  and  examinations  followed 
with  Dr.  A.  T.  Cabot,  Dr.  R.  C.  Cabot  and  Dr.  F.  C.  Shattuck, 
the  upshot  of  all  of  which  was  that  we  were  unable  to  deter- 
mine definitely  the  nature  of  the  tumor,  but  found  a  decided 
secondary  anemia,  and  reason  enough  in  the  patient's  condi- 
tion for  making  an  exploratory  operation. 

^  The  causes  of  hematuria  are  numerous  enough ;  one  thinks 
especially  of  bladder  tumor,  of  acute  infections  of  the  bladder, 
of  renal  stone  and  of  renal  tumor.  Besides  these,  there  is  the 
well-recognized  malarial  hematuria  of  the  tropics.  In  the 
case  of  Mr.  Lemoyne  we  were  justified  at  first  in  ruling  out 
lesions  of  the  bladder  and  kidney,  because  no  tumors  could 
be  felt,  nor  did  the  urinary  examination  point  to  damage  of 
those  organs;  indeed,  at  no  time  was  the  sediment  positively 
indicative  of  bladder  or  renal  disturbance. 

^  A  colon  distended  with  air  overlies  the  kidney  and  masks 
a  kidney  tumor;  conversely,  a  distended  colon  should  push 


EXPLORATORY  LAPAROTOMY.  39 

up  before  it  and  cause  to  protrude  anteriorly  a  tumor  of  the 
spleen.  In  the  case  under  consideration  we  seem  to  have  been 
misled  by  the  size  of  the  tumor  and  the  possible  slipping  aside 
of  the  distended  colon,  which  occasionally  is  extremely  mov- 
able on  account  of  a  long  mesocolon  or  mesosigmoid. 

On  the  1 2th  of  October,  Dr.  A.  T.  Cabot  explored  the  pa- 
tient's abdomen,  opening  down  upon  the  tumor  through  a 
lateral  incision  and  turning  aside  the  peritoneum.  The 
operator's  hand  behind  the  peritoneum  discovered  instantly 
that  the  tumor  was  a  tumor  of  the  kidney,  while  a  normal 
spleen  could  be  palpated  high  under  the  costal  arch.  The 
tumor  —  a  sarcoma  —  had  by  this  time  reached  a  considerable 
size,  and  was  as  large  as  two  closed  fists,  at  least.  It  was  re- 
moved readily,  but,  unfortunately,  masses  of  what  appeared  to 
be  malignant  tissue  were  found  involving  the  veins  and  extend- 
ing into  the  pelvis  of  the  kidney.  The  patient  made  the 
expected  prompt  recovery  from  the  operation,  but  metastases 
rapidly  developed.  Two  months  after  the  operation  he  had 
a  succession  of  convulsions  and  experienced  a  period  of 
unconsciousness,  with  symptoms  suggesting  a  metastasis 
in  the  brain.  Eventually  he  died,  after  a  tedious  illness, 
about  four  months  after  the  operation. 

There  were  several  unusual  and  interesting  points  in  the 
case  of  Mr.  Lemoyne.  His  history  of  malaria  and  his  long 
residence  in  the  tropics  were  misleading;  his  apparent  improve- 
ment under  anti-malarial  treatment  was  puzzling ;  the  slow 
growth  of  the  tumor  and  its  apparent  shrinkage  at  times  led 
us  away  from  a  true  diagnosis;  while  the  test  of  distending 
the  colon  failed  entirely  to  give  the  usual  evidence.  In  a  word, 
here  was  a  case  of  sarcoma  of  the  kidney  which  went  un- 
recognized for  more  than  a  year,  although  seen  and  studied 
by  a  number  of  competent  persons. 


PERFORATED  ABDOMEN. 

Case  12.  On  the  afternoon  of  April  8,  1910,  I  was  called 
hurriedly  into  the  country  to  see  a  man  who  was  said  to  have 
received  a  severe  abdominal  wound  within  the  hour.  I 
report  his  case  because  it  illustrates  the  possibility  of  recovery 
from  injuries  of  the  most  serious  nature.  The  patient,  Martin 
Pierce,  was  thirty-one  years  old.  A  large,  powerful,  athletic 
young  man,  six  feet  two  inches  in  height,  whose  occupation 
was  that  of  a  sawyer;  that  is  to  say,  he  operated  a  saw  mill' 
and  used  commonly  a  circular  saw  of  great  weight. 

At  the  time  of  his  injury,  he  was  standing  at  the  door 
of  his  mill,  about  eight  feet  from  the  machine,  when  the  saw 
burst,  and  one  heavy  piece,  shaped  like  a  lance-head  and  weigh- 
ing some  fifty  pounds,  flew  against  him  with  great  violence, 
and  penetrated  his  abdomen.  Covered  with  blood,  and  with 
protruding  intestines,  he  was  carried  to  his  house  near  by, 
and  was  seen  almost  immediately  by  his  physician,  who 
summoned  me. 

When  I  arrived  there,  two  hours  later,  I  found  the  patient 
in  excellent  condition.  The  bowel  had  returned  into  the  ab- 
domen, the  wound  was  carefully  bandaged,  the  man's  pulse 
was  76,  and  his  temperature  100°.  He  was  quite  rational,  and 
did  not  appear  particularly  ill.  There  had  been  no  evidence 
of  hemorrhage  from  the  rectum,^  nor  was  blood  found  in  the 
urine.  His  heart  action  was  vigorous,  and  his  lungs  sound. 
On  exposing  the  abdomen,  I  found  a  ragged  three-inch  wound 
through  the  left  rectus  muscle,  just  above  the  level  of  the 
navel. ^  The  bandages  were  not  very  bloody,  and  my  first 
impression  was  that  the  wound  was  merely  a  damage  to  the 
abdominal  wall.  With  the  patient  under  ether,  I  rapidly 
enlarged  the  wound,  and  explored  the  abdominal  cavity; 
immediately  there  was  a  great  gush  of  blood  and  clots, 
mingled  with  some  fecal  matter,  in  all  something  over  a  pint. 
I  turned  out  the  neighboring  intestines,  and  disclosed  three 

41 


42  SURGICAL    PROBLEMS. 

large  spurting  arteries  in  the  mesentery  of  the  jejunum. 
The  jejunum  itself  was  lacerated  at  two  points.  The  neighbor- 
ing transverse  colon  fortunately  was  not  damaged. 

^  The  passage  of  blood  from  the  rectum  is  traditionally 
regarded  as  evidence  of  intestinal  perforation.  In  practice, 
such  passage  of  blood,  associated  with  intestinal  perforation, 
is  not  especially  common,  since  a  paralysis  of  peristalsis 
usually  follows  immediately  on  intestinal  trauma.  The 
examining  surgeon  may  find,  on  percussion,  evidence  of  free 
gas  in  the  abdominal  cavity ;  —  tympany  over  the  Hver,  for 
example. 

Some  operators  have  sought  to  demonstrate  intestinal 
perforation  by  pumping  air  or  some  harmless  gas  into  the 
rectum,  and  looking  for  its  escape  into  the  abdominal  cavity. 
Such  measures  are  needless,  inexact,  and  time-consuming. 
In  any  case  of  doubt,  the  surgeon  should  explore  promptly 
the  abdominal  cavity. 

^  A  penetrating  wound  at  this  site  suggests  damage  to 
various  viscera,  depending  on  the  direction  of  entrance  of  the 
projectile.  One  expects  for  a  certainty  to  find  wounded  intes- 
tines, but  in  addition  one  must  look  for  wounds  of  the  stomach, 
pancreas,  the  left  kidney,  the  ureter,  and,  most  important 
of  all  perhaps,  the  large  arterial  and  venous  trunks.  Damage 
to  the  urinary  apparatus  is  nearly  always  followed  by  escape 
of  blood  into  the  bladder,  unless  the  ureter  is  severed. 

Demonstrate  bloody  urine  by  catheterizing.  Damage 
to  the  stomach  and  pancreas  is  commonly  followed  by  vomit- 
ing and  profound  collapse.  Damage  to  the  great  blood  vessels 
results  in  death  in  a  very  few  minutes. 

Having  satisfied  myself  that  the  damage  in  this  case  was 
confined  to  the  intestines  and  the  mesentery,  I  rapidly  re- 
paired those  structures,  taking  great  pains  in  suturing  the 
mesentery  not  to  cut  off  the  blood  supply  from  the  intestines. 
In  order  further  to  provide  for  possible  intestinal  necrosis, 
the  damaged  gut  was  wrapped  in  two  gauze  wicks,  which  were 
led  out  of  the  abdominal  wound  as  drains.  The  abdominal 
cavity  in  the  neighborhood  of  the  wound  was  carefully 
wiped  out,  not  irrigated,  and  the  abdominal  wound  was  par- 
tially closed  about  the  drainage  wicks. 

At  the  end  of  the  operation,  the  patient's  condition  was 
excellent,  and  his  pulse  80.     He  was  put  to  bed  in  a  semi- 


PERFORATED   ABDOMEN.  43 

Upright  position,  and  the  gentle  continuous  rectal  injection 
of  salt  solution  was  begun  (proctoclysis). 

This  injection  succeeds  admirably  in  keeping  down  thirst, 
in  supplying  fluids  to  the  circulation,  and  in  stimulating  an 
abundant  drainage  from  the  abdominal  cavity. 

Greatly  to  my  satisfaction,  the  patient  recovered  without 
a  bad  symptom.  At  the  end  of  three  days,  he  was  taking 
liquids  by  the  mouth;  at  the  end  of  a  week  he  was  put  upon 
a  fairly  nutritious  diet,  and  at  the  end  of  six  weeks  his  physi- 
cian reported  him  as  practically  well  and  about  to  return  to 
work. 


STERILITY. 

Case  13.  On  the  21st  of  December,  1908,  Mrs.  Henry 
Ford,  a  young  matron  twenty-three  years  old,  was  brought 
by  her  mother-in-law  to  consult  me.  One  could  scarcely 
look  for  a  greater  contrast  than  these  two  women  presented ; 
the  young  patient,  slight,  girlish,  pink  cheeked,  diffident; 
the  elder  woman,  robust,  mature,  masterful,  bearded,  strident. 

I  heard  little  of  her  story  from  the  patient  in  that  interview. 
The  mother-in-law  held  the  floor,  and  described  in  embarrass- 
ing detail  the  character,  the  symptoms  and  the  sufferings  of 
her  daughter.  I  was  told  that  the  young  woman  was  her 
husband's  social  inferior,  that  the  two  young  people  had 
made  a  runaway  match ;  that  the  patient  was  a  mere  school- 
girl, uneducated  and  hysterical;  that  she  was  dependent  for 
her  living  on  her  husband's  mother;  that  although  married 
five  years  she  had  never  been  pregnant;  that  for  three  years 
she  had  complained  of  excessive  pain  at  the  beginning  of  or 
immediately  before  the  catamenia,  which  came  every  twenty- 
six  days;  that  the  pain  was  excruciating,  low,  median  and 
shooting  into  the  right  breast  and  down  both  legs  ^ ;  and  that 
the  pain  was  relieved  after  the  passing  of  a  few  clots.  The 
mature  -speaker  proclaimed  the  patient's  symptoms  to  be 
more  or  less  fanciful,  but  admitted  that  she  had  borne  no 
children,  and  that  something  should  be  done  to  relieve  her 
sterility.^  I  was  allowed  to  examine  young  Mrs.  Ford  without 
the  presence  of  her  mother-in-law,  and  learned  that  the 
description  of  her  symptoms  was  correct.  She  appeared  as  a 
young  girl;  I  found  nothing  peculiar  In  the  abdomen,  but  in 
the  pelvis  a  uterus  of  small  size,  retrocessed  and  retroverted. 
The  cervix  was  long,  and  the  os  extremely  srnall. 

^  This  train  of  symptoms  and  pain  preceding  the  flow 
suggest  especially  two  possible  derangements,  either  an 
ovarian  neuralgia,  due  to  the  pelvic  engorgement  always 
preceding  catamenia,  or  to  an  obstruction  to  the  outflow  from 
the  uterus  by  an  abnormal  and  narrowed  pass.     I  have  found 

45 


46  SURGICAL    PROBLEMS. 

ovarian  neuralgia  of  this  type  to  be  readily  cured  by  cutting 
the  ovarian  nerves  in  the  broad  ligaments.  This  does  not 
interfere  with  the  generative  function.  Obstruction  at  the 
OS  must  be  treated  by  some  form  of  dilatation. 

2  Every  practitioner  will  recognize  the  absurdity  of  the 
interview  I  have  described.  Doubtless  in  many  cases  a 
young  girl,  or  a  married  woman  who  has  not  borne  children, 
should  interview  her  physician  in  the  presence  of  an  experi- 
enced member  of  her  family,  but  the  physician  will  do  well 
always  to  talk  later  with  the  patient  in  private,  if  he  is  to  get 
at  the  true  facts  of  the  case,  and  the  patient's  version  of  her 
ailment.  Needless  to  say,  a  pelvic  examination  should  always 
be  made  in  the  presence  and  with  the  assistance  of  a  nurse, 
whenever  possible. 

I  employed  a  simple  operation  for  Mrs.  Ford's  relief. 
First,  the  long,  tapering  cervix  with  its  narrow  os  was  widely 
dilated ;  then  a  thick  hollow  glass  plug  was  stitched  into  the 
cervix  with  catgut,  and  made  to  penetrate  beyond  the  internal 
OS.  The  abdomen  was  then  opened  by  the  transverse  Pfan- 
nensteil  incision;  the  uterus  was  drawn  up,  and  secured  in  a 
position  of  normal  anteversion,  by  crossing  and  stitching 
together  the  round  ligaments  outside  of  the  recti. 

I  think  highly  of  the  transverse  incision  in  the  case  of 
simple  work  within  the  pelvis.  This  incision  after  healing 
leaves  the  patient  with  an  unusual  sense  of  strength  and 
support,  while  incidentally  the  resulting  scar  is  almost 
imperceptible. 

Two  weeks  after  the  operation  Mrs.  Ford  went  home. 
At  the  end  of  six  weeks  the  plug  came  out;  her  subsequent 
menstrual  period  was  painless  and  normal,  and  in  due  course 
she  became  pregnant  and  went  on  to  an  uncomplicated  con- 
finement. 


THE  BREAST. 

Case  14.  On  the  9th  of  June,  1908,  a  married  woman, 
fifty-six  years  old,  consulted  me  regarding  a  swelling  in  her 
breast.  She  was  a  stout,  vigorous,  active  person,  accustomed 
to  exacting  work  as  the  keeper  of  a  lodging  house,  and  little 
introspective.  She  told  me  she  had  always  been  well,  except 
for  frequent  and  somewhat  disabling  attacks  of  "  chronic 
rheumatism."  ^  She  then  informed  me,  with  a  note  of  apol- 
ogy for  my  trouble,  that  for  four  years  previously  she  had 
carried  a  lump  in  her  left  breast.  Incidentally,  she  had  never 
borne  children.  At  various  times  during  the  four  years 
she  had  shown  the  lump  to  her  family  physician,  who  made 
light  of  it,  and  assured  her  that  it  was  just  one  of  those 
lumps  common  to  fat  women  in  their  advancing  years.  She 
had  therefore  disregarded  the  lump  until  two  weeks  before 
I  saw  her,  when  she  found  it  to  have  become  obviously  larger. 
This  alarmed  and  distressed  her  a  good  deal,  although  there 
were  no  further  symptoms,  no  impairment  of  her  general 
health,  and  no  pain.  I  examined  both  breasts  carefully, 
and  found  in  the  left  one  a  small  tumor,  not  at  first  apparent, 
owing  to  the  great  size  of  the  woman's  breast,  which  must 
have  weighed  ten  or  twelve  pounds.^  The  tumor  was  about 
the  size  of  a  child's  fist,  and  was  placed  in  the  inner  and  upper 
quadrant  of  the  breast.  A  further  enlargement  of  the  tissues 
was  found  along  the  pectoral  line,  running  up  towards  the 
axilla,  but  no  enlarged  nodes  could  be  felt  either  in  the  axilla 
or  in  the  cervical  triangles.^ 

^  It  is  interesting  to  note  the  frequency  with  which  victims 
of  malignant  tumor  complain  of  long-standing  rheumatism. 
I  call  the  attention  of  my  professional  readers  to  this  fact, 
and  ask  them  to  observe  it  in  their  future  cases  of  malignant 
disease. 

Mt  is  much  more  difficult  to  detect  a  tumor  in  a  large,  pen- 
dulous breast  than  in  a  small,  flat  and  shriveled  breast. 
Sit  before  your  patient,  whose  chest  must  be  widely  exposed, 

47 


48  SURGICAL    PROBLEMS. 

and  examine  both  breasts  carefully,  rolling  them  against  the 
chest  wall,  under  your  outspread  palms,  then  pick  up,  and 
handle  carefully  every  suspicious  nodule.  Should  you  find 
no  tumor  at  first,  stand  behind  your  patient  as  she  sits;  pass 
your  hands  from  behind  over  her  shoulders,  and  then  at  a 
great  advantage,  roll  and  palpate  the  breast.  Then  examine 
the  axilla.  Direct  the  nurse  to  hold  the  patient's  arm  at  a 
right  angle,  and  flexed ;  pass  your  outstretched  fingers  into 
the  axilla  high  in  front,  and  explore  carefully  the  apex  of  the 
axilla,  and  the  pectoral  margin;  with  your  hand  still  pressed 
up  into  the  axilla,  have  the  patient's  arm  then  brought  firmly 
to  her  side.  This  will  often  bring  out  and  accentuate  enlarged 
nodes,  hitherto  impalpable. 

^  The  nature  of  breast  tumors  cannot  always  be  determined 
by  palpation.  In  general  terms,  benign  tumors  are  more 
or  less  clearly  outlined,  and  are  movable;  whereas  malignant 
tumors  seem  to  infiltrate  surrounding  tissues,  and  to  be  fixed, 
but  the  evidences  are  not  invariable;  cystic  and  fibrous 
tumors  may  take  on  malignant  characteristics,  and  still  feel 
like  benign  tumors;  while  at  the  same  time  certain  chronic 
inflammatory  processes  may  closely  simulate  cancer.  Re- 
member always  that  eighty  per  cent  of  all  breast  tumors  are 
malignant,  and  that  a  woman's  youth  gives  no  assurance  of 
immunity. 

I  operated  on  this  woman,  a  few  days  later,  and  made  a  most 
extensive  dissection,  removing  a  wide  area  of  skin  down  to 
the  lower  rib  margin,  to  the  sternum,  and  high  into  the  axilla, 
together  with  the  pectoral  muscles  and  the  axillary  contents. 
This  was  the  largest  breast  tumor  I  have  ever  removed.  It 
weighed  in  all  fourteen  pounds.  The  patient  suffered  severely 
from  shock,  and  made  a  slow  convalescence,  which  was 
hastened  so  far  as  possible  by  extensive  skin  grafting.  She 
went  home  well  at  the  end  of  three  weeks.  I  felt  little  hope 
that  the  operation  would  be  permanently  curative,  the  long 
course  of  the  tumor  (four  years)  and  the  great  extent  of  the 
tissue  involved  rendered  an  operative  cure  improbable. 
Six  months  after  the  operation,  the  patient  appeared  well. 
She  was  buoyant,  happy  and  vigorous,  and  rejoiced  that 
the  operation  was  behind  her.  A  year  after  the  operation, 
however,  she  developed  symptoms  of  pulmonary  disease, 
which  rapidly  extended  to  the  liver  and  other  abdominal 
organs.      She   died   seventeen   months   after   the   operation, 


THE    BREAST.  49 

but  there  was  never  a  recurrence  at  the  site  of  the  original 
disease. 

There  are  three  interesting  points  in  connection  with  this 
case:  the  long  continuance  of  the  disease,  the  great  size 
of  the  tumor  and  the  fact  that  no  local  recurrence  took  place. 
Although  the  patient  died  of  internal  cancer,  the  case  gives 
us  a  sort  of  negative  encouragement.  I  feel  strongly  that  the 
extensive  dissection  would  have  saved  the  woman's  life  had 
it  been  done  three  years  earlier. 


50  SURGICAL    PROBLEMS. 

Case  15.  Miss  Mary  Farmer,  a  clerk  in  a  large  down-town 
office,  was  forty-six  years  of  age  when  she  consulted  me  on 
Dec.  30,  1908,  by  the  advice  of  her  physician.  She  was  one 
of  those  fretful,  teary,  middle-aged  women,  from  whom  it 
is  extremely  difficult  to  extract  a  clear  story.  She  told  at 
length  of  twenty  years  devoted  to  the  care  of  bilious  head- 
aches, blurring  of  vision,  constipation  and  insomnia.  Five 
years  before  I  saw  her  she  had  been  operated  upon  for  gall- 
stones, but  no  gallstones  were  found,  and  her  symptoms 
had  not  been  relieved.  Two  years  after  the  gallstone  opera- 
tion —  that  is  to  say,  three  years  before  she  consulted  me  — 
she  began  to  be  troubled  by  a  slight  swelling  in  the  left  breast, 
irregular  menstruation,  and  a  fullness  on  the  front  of  the  neck.^ 
The  condition  of  the  breast  especially  attracted  my  attention. 
The  patient  stated  that  although  this  swelling  had  existed 
for  three  years,  it  had  caused  no  special  disturbance,  no  pain 
or  dragging.  She  would  not  have  consulted  a  surgeon  had 
it  not  been  for  the  insistence  of  her  family  physician. 

There  was  much  about  Miss  Farmer  to  suggest  some  serious 
ailment.  Though  tall  and  well  developed  she  was  emaciated, 
pale  and  feeble-looking.  She  was  apprehensive  also,  and  sub- 
mitted with  anxiety  to  an  examination.  I  found  nothing 
remarkable  about  the  neck,  nor  were  the  abdomen  and  chest 
peculiar.  On  examining  the  left  breast,  which  was  somewhat 
atrophied  and  easily  palpated,  I  found  in  the  upper  and 
outer  quadrant  a  mass  the  size  of  a  hen's  egg,  somewhat 
movable,  semi-fluctuant  and  not  tender.  There  were  no  en- 
larged nodes  in  the  axilla  or  neck.^ 

^  Irregular  menstruation,  blurring  of  vision  and  a  fullness 
of  the  neck  immediately  suggests  the  possibility  of  Graves' 
disease.  One  looks  for  tachycardia,  tremor,  prominent  eyes, 
lagging  lids,  and  other  nervous  and  digestive  disturbances; 
for  tachycardia  and  tremor  especially.  In  the  case  of  Miss 
Farmer  these  signs  were  absent. 

^  The  diagnosis  in  this  case  was  less  evident  than  at  first 
appears.  A  movable  tumor  seems  to  render  improbable  malig- 
nancy, but  we  know  that  tumors  for  a  long  time  movable 
may  become  malignant.  One  thinks  especially  of  fibro-epi- 
thelial  tumors,  and  the  five  varieties,  —  periductal  fibroma, 
periductal  myxoma,  periductal  sarcoma,  fibro-cystadenoma, 


THE   BREAST.  51 

and  papillary  cystadenoma,  the  more  usual  forms  of  fibrous 
breast  tumors.  Of  these,  any  one,  especially  cystadenomata, 
may  take  on  malignant  characteristics,  so  that  in  operating 
on  these  tumors,  in  cases  of  middle-aged  women,  one  must 
give  a  guarded  prognosis;  and  should  examine  carefully  at 
operation  the  histological  character  of  the  growth,  in  order 
to  determine  the  extent  of  operation  necessary.  In  this  partic- 
ular case,  the  diagnosis  was  not  altogether  obvious.  The 
duration  of  the  disease  suggested  a  chronic  non-malignant 
process,  but  the  constitutional  impairment  of  the  patient 
and  her  age  imposed  a  careful  prognosis,  with  the  thought 
in  mind  of  possible  malignant  changes  in  the  tumor. 

A  week  after  seeing  the  patient  I  operated  upon  her  breast, 
by  means  of  that  exploratory  method  which  we  call  plastic 
resection:  carrying  a  crescentic  incision  half  way  around  the 
breast  on  its  outer  and  lower  margin,  turning  the  gland  over, 
and  so  removing  the  tumor  from  beneath  it.  I  was  then  able 
quickly  to  determine  the  nature  of  the  growth,  and  found  it 
to  be  a  fibro-cystic  affair  with  no  evidence  of  malignancy. 
The  breast  was  then  laid  back  in  its  normal  position  and  the 
wound  closed.  The  patient  has  remained  perfectly  well  ever 
since,  while  the  scar  beneath  the  breast  is  scarcely  to  be 
observed.* 


*The  reader  may  well  compare  Case  15  with  Case  14.  The  histories  of  the 
two,  the  ages  of  the  patients,  and  the  character  of  the  symptoms  are  not  dis. 
similar.  One  proved  to  be  malignant,  and  fatal;  the  other  was  benign,  and  the 
patient  easily  cured. 


52  SURGICAL    PROBLEMS. 

Case  i6.  On  the  14th  of  June,  1910,  I  was  asked  by  a 
physician  to  see  a  patient  who  was  said  to  be  suffering  from 
an  advanced  disease  of  the  breast.  This  patient,  Mrs.  John 
Anderson,  had  been  a  vigorous  woman  up  to  the  age  of  fifty- 
one,  two  years  before  I  saw  her.  For  many  years  she  had  been 
a  firm  believer  in  Christian  Science,  and  was  convinced,  with 
much  show  of  reason,  that  her  faith  had  saved  her  from  many 
ills.  She  was  the  wife  of  a  dentist,  who  concurred  somewhat 
reluctantly  in  his  wife's  philosophy  of  life.  At  the  age  of 
fifty-one,  then,  Mrs.  Anderson,  when  in  sound  health,  first 
noticed  a  small  lump  in  her  left  breast.  Quite  undismayed 
she  consulted  at  once  a  Christian  Science  healer,  who  pro- 
ceeded to  exorcise  the  evil.  Mrs.  Anderson  persisted  in  this 
method  of  treatment  for  eighteen  months,  during  which  time 
the  lump  continued  to  grow,  and  broke  down  into  a  deep  and 
offensive  ulcer  on  the  surface  of  the  breast.  The  patient 
finally  concluded  that  she  must  seek  further  assistance. 
Instead  of  consulting  a  physician,  she  followed  the  promptings 
of  a  curious  mental  irrationality,  and  toured  the  country, 
putting  herself  in  the  hands  of  various  quacks.  At  length, 
in  April  of  1910,  nearly  two  years  after  her  first  knowledge 
of  the  disease,  she  consulted  an  experienced  surgeon  in  Minne- 
sota, who  explained  to  her  the  nature  of  her  illness,  and  its 
hopelessness.^  Nothing  daunted  and  still  convinced  of  the 
efficacy  of  mental  treatment,  and  the  insignificance  of  her 
physical  being,  Mrs.  Anderson  returned  to  her  home  in 
Boston,  where  she  called  in  a  physician,  apparently  with  the 
idea  that  such  a  person  could  render  her  life  more  tolerable, 
and  herself  less  of  an  offense  to  her  family.  At  this  time  I  saw 
Mrs.  Anderson  with  a  view  to  some  sort  of  an  operation. 
I  found  her  to  be  a  tall,  fine  looking  and  spirited  middle-aged 
woman,  dwelling  in  some  sort  of  an  intangible  mental  atmos- 
phere which  I  endeavored  in  vain  to  penetrate.  I  am  familiar 
with  the  vagaries  of  Christian  Scientists,  and  with  the  teach- 
ings of  psychology,  but  the  attitude  of  this  woman  embraced 
neither.  So  far  as  I  could  judge,  her  beliefs,  if  I  may  call  them 
so,  were  founded  on  a  curious  combination  of  fatalism  and 
sorcery. 

On  physical  examination  I  discovered  a  left  lung  partially 


THE    BREAST.  53 

solidified,  and  an  enlarged  liver.  The  left  breast  was  nearly 
destroyed  by  a  malignant  growth,  which  bore  in  its  center 
a  deep  sloughing  ulcer  al)out  the  size  of  a  teacup. 

The  problem  in  this  case  was.  What  should  we  do?  No 
radical  operation  was  possible.  On  the  other  hand,  I  felt 
that  something  should  be  done  to  correct  the  extreme  misery 
of  the  patient's  condition.  She  was  an  offense  to  all  who  came 
near  her.  The  room  in  which  she  sat  reeked  of  a  foul,  gangre- 
nous odor,  which  she  seemed  not  to  notice,  while  the  dressing  of 
her  breast  was  distressing  in  the  highest  degree.  Accordingly 
I  advised,  and  helped  to  carry  out,  a  palliative  operation,  to 
convert  a  filthy  sore  into  a  clean,  granulating  wound.  The 
operative  risk  in  this  case  was  not  inconsiderable,  for  the 
patient  was  deeply  toxic.  Accordingly  I  avoided  using  ether, 
and  carried  on  the  anesthesia  with  nitrous  oxide  and  oxygen, 
which  in  these  cases  lower  the  patient's  resistance  less  than 
does  ether.  With  the  knife  and  cautery  the  sloughing  mass  was 
widely  removed  down  to  apparently  sound  tissue.  Mrs. 
Anderson  rallied  promptly  from  her  operation,  and  was  able 
to  sit  up  two  or  three  days  later.  We  then  instituted  the  treat- 
ment for  inoperable  cancer,  which  I  have  followed  at  the  in- 
stance of  Dr.  G.  W.  Gay  during  the  past  three  years.  ^  Whether 
or  not  this  treatment  influenced  favorably  her  condition,  I  can- 
not say.  It  is  certain,  however,  that  her  life  was  far  more 
tolerable  than  before  the  operation.  She  lived  for  two  months, 
and  died  quietly  of  exhaustion. 

^  It  is  evident  that  at  this  time  Mrs.  Anderson  was  far  gone 
with  cancer,  which,  beginning  in  the  breast,  had  destroyed 
that  organ,  and  had  involved  the  chest  and  liver. 

^  This  treatment  consists  in  giving  five  drops  of  the  com- 
pound solution  of  iodine,  three  times  a  day,  and  increasing 
the  dose  rapidly,  until  by  the  end  of  a  month  the  patient  is 
receiving  from  sixty  to  one  hundred  drops  in  the  twenty-four 
hours.  Frequently,  by  the  use  of  this  drug,  pain  is  allayed, 
the  rapidity  of  the  tumor's  growth  seems  to  be  checked, 
and  life  is  prolonged.  It  may  be  necessary  to  supplement 
the  iodine  by  minute  and  frequently  repeated  doses  of  opium 
for  a  short  time. 


DIGESTIVE  DISORDERS. 

Case  17.  A  young  boy  of  fifteen,  from  one  of  the  state 
institutions,  recently  came  under  my  care  at  the  Massachu- 
setts General  Hospital.  He  was  sent  in  as  a  case  of  chronic 
appendicitis,  by  the  institution  physician,  and  he  turned 
out  to  be  an  old  haunter  of  hospitals,  which  he  preferred  to 
state  institutions.  His  story  so  far  as  we  could  gather  it, 
ran  something  like  this:  Born  in  poverty  and  reared  in  the 
most  forlorn  surroundings,  he  had  never  until  recently  re- 
ceived proper  food  or  proper  bodily  care.  From  his  earliest 
years  he  had  been  indulged  occasionally  in  alcohol,  and  was 
an  inveterate  smoker  of  scrag  tobacco.  He  had  always  been 
subject  to  stomach  ache  and  to  attacks  of  nausea  and  vomit- 
ing. Food  frequently  distressed  him,  his  sight  was  poor, 
he  became  easily  tired ;  he  had  had  typhoid  fever,  scarlet  fever, 
measles,  whooping  cough,  rickets,  consumption,  spotted  fever, 
and  various  other  ailments.  Whenever  he  went  home,  his 
drunken  father  beat  him  into  insensibility,  while  worst  of  all 
he  was  the  victim  of  an  obstinate  chronic  constipation,  in 
spite  of  two  years  of  wholesome  life  spent  at  a  Poor  Farm. 
Such  was  the  lad's  melancholy  tale,  which  was  received  by 
the  house  surgeon  with  incredulity.  On  examining  this 
unfortunate  youth,  I  found  him  to  be  a  vigorous,  well-grown 
boy,  rather  large  for  his  years;  well  developed,  ruddy,  restless, 
and  with  the  usual  shrewd  intelligence  of  a  street  urchin. 
There  was  no  evidence  about  him  of  any  organic  or  functional 
disorder.  The  only  fact  which  emerged  from  his  story  was 
that  he  did  actually  suffer  from  an  obstinate  constipation. 
I  could  detect  no  evidence  of  a  troublesome  appendix,  while 
on  cross  examination  his  claim  of  former  attacks  of  appen- 
dicitis fell  to  the  ground.  Indeed,  I  could  make  nothing  of 
the  matter  except  that  the  boy  was  doubtless  a  malingerer, 
a  supposition  confirmed  by  learning  that  he  had  been  many 
times  in  hospitals,  and  that  he  had  a  fancy  for  an  appendicitis 
operation,  which  would  doubtless  lend  variety  to  his  life  and 

55 


56  SURGICAL    PROBLEMS. 

keep  him  in  the  hospital  for  several  weeks.  A  few  years  ago  I 
should  have  discharged  this  patient  at  once,  but  I  have  become 
interested  in  treating  by  a  simple  operation  the  constipation 
of  young  persons.  I  told  the  lad  that  I  should  not  operate 
upon  him  for  appendicitis,  but  for  constipation.  He  consented 
cheerfully.  I  then  etherized  him,  and  thoroughly  stretched 
the  sphincter  ani  muscle.  The  next  day  but  one,  his  bowels 
moved  naturally,  without  enema  or  cathartic.  I  kept  him 
a  week  in  the  hospital,  during  which  period  he  had  one  or 
two  normal  daily  movements.  He  regained  quickly  control 
of  the  sphincter.  Since  that  time,  I  am  informed  that  he  has 
had  no  more  constipation.^ 

^  The  rationale  of  the  sphincter  stretching  is  simple  enough. 
Ordinary  constipation  is  a  matter  of  habit,  as  is  well  known, 
unless  there  be  some  colon  or  rectal  abnormality,  —  relatively 
rare  conditions.  The  average  uninstructed  young  person 
pays  no  attention  to  the  condition  of  his  bowels,  allows  them 
to  become  loaded,  then  exercises  unduly  both  his  abdominal 
muscles  and  his  sphincter  in  their  evacuation,  and  so  in  the 
course  of  time  develops  an  unnaturally  vigorous  and  close 
anal  ring.  If  you  examine  such  a  sphincter  you  will  find  your 
finger  to  enter  with  difficulty,  and  to  be  grasped  tightly  by  the 
muscle.  Fecal  masses  pass  with  equal  difficulty,  constipation 
ensues,  and  a  vicious  circle  is  established.  The  operation 
of  stretching  paralyzes  the  sphincter  for  the  time  being,  nat- 
ural daily  movements  result,  a  proper  psychic  influence 
is  established,  and  the  patient  is  frequently  cured  of  his 
constipation. 


DIGESTIVE    DISORDERS.  57 

Case  i8.  In  1901  Mrs.  B.  R.  Adams  had  been  a  victim  of 
gallstones  for  five  years,  she  told  me.  She  was  then  thirty-six 
years  old.  She  had  consulted  various  physicians,  and  suffered 
various  treatment,  iBut  without  permanent  benefit.  She  said 
that  her  attacks  were  increasing  in  frequency.  Of  a  constipated 
habit  in  childhood,  she  had  grown  dependent  on  cathartic 
medicines ;  her  appetite  was  always  small  or  nil.  She  had  fre- 
quent headaches,  was  continually  conscious  of  a  weight 
and  dragging  in  the  epigastrium  and  was  occasionally  nau- 
seated and  "  bilious."  About  once  in  two  months  she  had 
an  attack  of  what  she  called  acute  gallstone  colic,  agonizing 
pain  in  the  epigastrium  coming  on  gradually  and  lasting 
from  two  to  twenty-four  hours,  relieved  by  morphine  only. 
My  examination  seemed  to  justify  the  conclusion  of  her  pre- 
vious advisers.  She  was  a  large  woman,  somewhat  fat,  some- 
what lethargic,  highly  intelligent,  and  with  nothing  of  con- 
sequence in  her  previous  history.  Her  tongue  was  slightly 
furred,  and  her  conjunctivae  slightly  yellow,  while  there  was 
distinct  tenderness  to  be  made  out  in  the  region  of  the  gall 
bladder,  in  the  center  of  the  epigastrium,  and  near  the  navel. ^ 
I  saw  Mrs.  Adams  a  week  later  in  one  of  her  gallstone  attacks. 
It  was  much  as  I  have  described,  and  I  had  no  hesitation  in 
assuring  her  that  she  had  a  chronic  infection  of  the  bile 
passages,  probably  gallstones,  and  that  she  should  have  an 
operation  for  their  removal.  Unfortunately  for  my  interest 
in  the  case  this  patient  lived  in  another  city.  She  went  home 
shortly  after  I  saw  her,  consulted  a  well-known  surgeon  there, 
and  was  operated  upon  as  I  had  advised.  The  operator 
explored  the  gall  bladder,  ducts  and  duodenum,  and  found 
them  to  all  appearances  normal;  no  stones,  no  evidence  of 
infection.  He  drained  the  gall  bladder  for  a  few  days,  however, 
and  the  patient  after  recovery  was  relieved  of  her  symptoms 
for  many  months.^ 

^  Tenderness  near  the  navel,  that  is,  on  a  line  between  the 
navel  and  the  gall  bladder  (ninth  costal  margin)  about  one 
inch  from  the  navel  is  strongly  indicative  of  past  or  present 
gall-bladder  disease.  Pressure  at  this  point  frequently  elicits 
a  sense  of  pain  or  discomfort  in  the  gall-bladder  region ;  and 
is  due  doubtless  to  the  resultant  slight  stretching  of  the  round 


58  SURGICAL    PROBLEMS. 

ligament  of  the  liver,  and  the  pulling  upon  delicate  adhesions 
in  the  upper  part  of  the  abdomen,  '*  the  cobwebs  in  the  attic 
of  the  abdomen  "  of  R.  T.  Morris. 

2  We  know  that  gallstones  are  due  to  an  infection  of  the  ducts 
and  gall  bladder.  We  believe  that  much  of  the  pain  of  bile- 
duct  disease  is  due  to  obstruction  of  the  ducts  through  swell- 
ing and  mucous  secretion,  and  is  not  necessarily  due  to  the 
presence  or  passage  of  gallstones.  In  operating  on  the  gall 
bladder,  therefore,  experience  teaches  us  to  drain  the  gall 
bladder  and  ducts  for  many  days  —  twelve  days  to  three 
weeks  —  in  order  to  subdue  the  Inflammation  which  is  fre- 
quently present.  When  the  Inflammation  has  subsided,  re- 
move the  drain.  The  drainage  sinus  will  then  close  in  a  few 
hours,  in  marked  contrast  to  the  long-delayed  closure  of  a 
sinus  drained  for  a  few  days  only,  and  commonly  with  ducts 
still  infected. 

My  patient  was  comfortable  and  In  good  health  for  a  year 
after  her  operation.  She  then  began  to  have  recurring  pains 
in  the  old  region,  pains  aggravated  especially  by  the  eating 
of  meat.  At  that  time  I  had  her  see  an  Internist,  who  assured 
her  that  her  pain  was  due  to  periodic  attacks  of  pyloric  spasm. 
She  had  then  a  marked  hyperchlorhydria,  accounted  a  common 
cause  of  painful  pyloric  spasm.  In  order  to  overcome  the 
acidity  and  spasm,  my  consultant  gave  Mrs.  Adams  a  long 
course  of  bicarbonate  of  soda,  and  subcarbonate  of  bismuth 
in  large  doses,  half  an  hour  before  meals.  She  was  greatly 
helped  by  this  treatment,  and  was  comparatively  well  for 
more  than  two  years,  when  she  became  less  careful  about 
taking  her  medicine,  which  at  the  same  time  seemed  to  have 
lost  something  of  its  efficacy.  Attacks  of  pain  then  began 
to  recur,  with  loss  of  appetite  and  general  debility;  her  out- 
look seemed  uncertain  and  distressing.  At  that  time  she  hap- 
pened to  be  visiting  In  the  country,  and  came  under  the  care 
of  an  extremely  competent  general  practitioner,  an  old 
friend  of  my  own.  This  physician  gave  her  a  most  thorough 
and  careful  examination.  He  found  the  old  hyperchlorhydria 
to  be  present  In  force,  and  the  old  tenderness  in  the  epigas- 
trium; at  the  same  time  the  constipation  was  very  marked, 
and  to  this  he  turned  his  attention  especially.  He  made  a  care- 
ful pelvic  examination,  and  found  the  sphincter  ani  to  be 
very  tight,  and  In  a  condition  of  tonic  spasm.     Immediately 


DIGESTIVE   DISORDERS.  59 

he  concluded  that  this  last  symptom  was  a  most  important 
feature  in  the  case.  He  urged  me  to  operate  at  once  by  dilat- 
ing the  sphincter,  and  explained  his  hopes  of  a  cure,  somewhat 
as  follows:  A  sphincter  in  tonic  spasm  causes  chronic  consti- 
pation; chronic  constipation  results  in  auto-intoxication; 
auto-intoxication  interferes  with  many  of  the  normal  functions 
of  the  body,  especially  with  the  functions  of  the  secreting 
glands;  a  hyperemia  of  the  abdominal  organs  frequently 
results;  incidentally  we  find  gastric  hyperchlorhydria;  this 
causes  pyloric  spasm  and  pain.  By  the  use  of  antacids  we 
attack  this  disease  from  the  wrong  end.  They  are  palliatives 
only.  Cure  the  constipation  and  you  will  cure  the  pain. 
I  accepted  so  much  of  this  train  of  reasoning  as  to  operate  for 
the  cure  of  the  constipation.    That  was  three  years  ago. 

Immediately  there  was  an  improvement  in  the  condition 
of  the  bowels,  and  in  the  course  of  a  week  all  cathartics  and 
injections  were  abandoned.  Since  that  time,  the  bowels 
have  acted  normally.  The  epigastric  pain  was  not  relieved 
with  equal  promptness,  but  the  attacks  decreased  in  fre- 
quency and  severity,  until  by  the  end  of  six  months  she 
realized  that  she  was  well.  For  more  than  two  years,  now, 
she  has  remained  well. 


60  SURGICAL    PROBLEMS. 

Case  19.  Priscilla  Marshall  was  twenty-nine  years  old 
when  she  came  to  consult  me  on  the  29th  of  March,  1908. 
She  was  an  unhappy-looking  young  woman,  unmarried,  and 
a  clerk  in  a  railway  office.  She  boasted  complacently  of  having 
been  well  up  to  the  time  of  taking  up  work,  four  years  before. 
Since  she  had  been  busy  as  a  wage-earner,  however,  her  health 
had  gradually  failed,  and  she  had  the  usual  dreary  tale  to 
tell,  which  we  hear  from  women  worn  out  Avith  long  hours 
of  exacting  office  work,  hot  rooms,  and  improper  food.  It 
was  difficult  to  get  at  her  story,  so  many  were  the  items  which 
she  pushed  to  the  front;  catamenia  painful  throughout, 
irregularity  of  the  bowels,  scalding  micturition,  occasional 
mucous  colitis,  inevitable  distress  immediately  after  food, 
occasionally  severe  pain  in  the  region  of  the  appendix,  morn- 
ing frontal  headache,  lack  of  appetite,  blurring  of  vision, 
occasional  nausea  after  food.^  Miss  Marshall  was  a  slight, 
nervous  young  woman,  of  apprehensive  and  somewhat  sullen 
bearing;  much  the  sort  of  person  one  guesses  might  readily 
be  influenced  for  her  good  by  the  ministrations  of  Christian 
Science.  A  careful  physical  examination  proved  disappoint- 
ing. The  eyes  were  normal,  the  thyroid  not  enlarged,  the 
pulse  was  80,  and  there  was  no  tachycardia.  The  tongue 
was  furred,  there  was  excess  of  gastric  hydrochloric  acid,  there 
was  some  ptosis  of  the  abdominal  organs,  and  a  markedly 
displaced  right  kidney.  All  parts  of  the  abdomen  were  tender, 
especially  over  the  appendix  and  the  ovarian  regions.  The 
uterus  was  slightly  retroverted  and  the  anal  sphincter  tight.  ^ 
At  first  I  was  minded  to  send  the  patient  off  to  a  general  practi- 
tioner, as  her  ailment  did  not  seem  to  be  surgical.  However, 
in  order  to  save  her  time  and  trouble,  I  gave  her  one  piece 
of  advice  which  was  most  important.  I  recommended  to  her 
a  quiet  country  place  for  three  weeks  of  rest  and  good  food. 
At  the  end  of  her  vacation,  she  returned  feeling  much  better, 
though  the  constipation  persisted,  and  the  anal  sphincter  was 
as  tight  as  ever.  Next  day  I  gave  her  nitrous  oxide  anesthesia, 
and  stretched  the  sphincter.  In  three  days  she  went  back  to 
her  work  with  her  constipation  apparently  cured.  It  has  re- 
mained cured  ever  since,  and  with  proper  regard  to  sleep,  food, 
exercise  and  Sunday  holidays  she  herself  has  continued  well. 


DIGESTIVE  DISORDERS.  6l 

^  The  train  of  symptoms  described,  and  the  type  of  patient, 
are  familiar  to  every  practitioner.  While  every  one  of  these 
symptoms  is  suggestive  and  appeals  to  various  specialists 
according  as  their  inclinations  prompt,  the  widely  experienced 
physician  will  see  that  the  condition  is  due  to  the  general 
lack  of  tone  of  the  whole  organism.  One  man  will  look  for 
and  will  find  a  ptosis  of  the  abdominal  organs,  due  to  congeni- 
tally  long  visceral  attachments  weakened  by  lack  of  exercise 
and  a  confining  occupation  ;  another  man  will  find  a  chronic 
hyperchlorhydria  with  a  descent  of  the  stomach  and  some 
pyloric  obstruction;  another  will  center  his  attention  on  the 
nervous  phenomena,  especially  on  the  mucous  colitis;  another 
will  think  first  of  thyroid  disease;  while  others  will  consider 
some  kidney  disturbance  or  some  permanent  change  in  the 
eyes;  and  the  active  surgeon  will  put  his  finger  at  once  on 
McBurney's  point,  and  call  for  a  removal  of  the  appendix. 

^  This  collection  of  findings  coincides  closely  with  the 
symptoms  which  the  patient  described.  The  undoubted 
ptosis  was  especially  conspicuous,  but  doubtless  many  persons 
have  an  equal  degree  of  ptosis  without  symptoms. 


62  SURGICAL    PROBLEMS. 

Case  20.  John  Strong  was  thirty-nine  years  old  when  he 
consulted  me  in  May,  1908.  He  was  a  slight,  athletic  man, 
weighing  one  hundred  and  thirty  pounds,  and  had  had  a  de- 
vious history.  At  the  age  of  twenty  he  contracted  syphilis,^ 
but  had  long  regarded  himself  as  cured.  This  misfortune 
befell  him  when  he  was  a  young  clerk  in  a  banking  house, 
and  he  had  remained  a  clerk  ever  since.  At  the  age  of  twenty- 
five  his  appendix  was  removed  in  the  middle  of  an  acute  attack 
of  appendicitis.  There  resulted  a  ventral  hernia,  occasional 
pain  in  the  scar,  and  an  obstinate  chronic  constipation. ^ 
At  the  age  of  thirty  he  had  a  severe  typhoid  fever,  which  left 
him  debilitated  for  a  long  time.  For  many  years  he  had  suf- 
fered from  chronic  sore  throat  with  enlargement  of  the  tonsils 
on  the  slightest  provocation.  For  five  years,  at  least,  he  had 
been  much  troubled  with  severe  frontal  headaches,  increasing 
now  in  frequency  and  acuteness.  The  year  before  I  saw  him 
he  had  suffered  from  a  violent  attack  of  "  indigestion  "  with 
jaundice,  and  severe  epigastric  pain  lasting  on  and  off  for 
one  month. ^  This  pain  had  recurred  three  times  during  the 
previous  year,  and  for  this  he  consulted  me.  He  married 
at  the  age  of  twenty-eight,  and  had  six  healthy  children. 

In  view  of  the  patient's  history,  I  approached  a  physical 
examination  with  much  uncertainty.  Bearing  in  mind  the 
malign  influence  of  an  old  syphilis,  I  could  not  exclude  the 
possibility  of  the  common  syphiloma  of  the  brain,  though 
absence  of  characteristic  vomiting  and  of  disturbance  of  the 
eyes  rendered  improbable  such  a  brain  disease.  There  were 
no  signs  of  disturbance  in  the  chest,  and  the  abdomen  itself 
gave  a  negative  answer  to  my  questions.  The  size,  position, 
and  activity  of  the  stomach  were  not  peculiar;  the  liver  was 
not  enlarged,  nor  was  there  any  tenderness  in  the  region  above 
the  navel;  no  masses  were  to  be  felt,  or  other  evidence  of 
tumors,  enlarged  nodes  or  matting  of  viscera.  I  was  obliged, 
therefore,  to  assume  that  the  jaundice  was  a  catarrhal  jaundice 
and  the  pain  due  to  the  passage  of  very  small  stones  or  of 
mucous  plugs, —  this  in  spite  of  the  fact  of  a  previous  typhoid 
fever.  There  remained  the  lower  portion  of  the  abdomen: 
This  was  in  no  way  peculiar,  except  for  the  appendix  scar. 
Deep   palpation   elicited  no    tenderness,    nor   was   anything 


DIGESTIVE   DISORDERS.  63 

abnormal  to  be  felt.  The  much-talked-of  appendix  scar  was 
small;  there  was  no  hernia  there,  but  a  slight  bulging  of  the 
rectus  muscle,  which  was  prominent  when  the  man  stood 
upright.  I  examined  his  rectum  and  sigmoid.  The  procto- 
scope entered  with  difficulty,  but  discovered  nothing  wrong. 
The  sphincter  muscle  was  very  tight,  and  the  patient  admitted 
having  an  obstinate  constipation,  due  to  frequent  neglect 
of  his  bowels;  —  and  normal  comfort  only  after  the  use  of 
laxatives  for  several  days.  The  problem  in  Mr.  Strong's 
case  seemed  to  be  complex;  the  great  saving  element  in  the 
situation  being  that  in  spite  of  many  complaints  and  diverse 
symptoms  he  appeared  to  be  in  excellent  general  health. 
Furthermore  he  was  apparently  a  case  for  an  internist.  The 
one  condition  about  him  which  seemed  easy  of  remedy  was 
the  tight  sphincter,  a  probable  cause  of  his  constipation. 
Accordingly  I  stretched  thoroughly  the  sphincter,  ordered  a 
coarse,  laxative  diet,  without  cathartics,  and  directed  the 
patient  to  report  to  me  in  three  weeks.  At  the  end  of  that  time 
he  proclaimed  himself  cured.  I  believe  he  has  remained  cured. 
Certain  it  is  that  occasionally  when  I  see  him  he  assures 
me  that  he  has  no  more  headache,  jaundice,  stomach  ache 
or  constipation. 

^  The  instance  of  an  old  syphilis  suggests  strongly  that  spe- 
cific infection  as  the  underlying  cause  of  many  of  his  symptoms, 
especially  headache  and  the  irritation  of  the  throat.  On  the 
other  hand,  an  examination  of  the  man's  eyes,  especially 
of  the  fundi,  showed  no  abnormalities.  There  was  no  Wasser- 
mann  reaction. 

-  The  appendix  operations  of  fifteen  years  ago  were  very 
serious  affairs,  and  not  infrequently  to-day  we  see  patients 
then  operated  upon,  with  grave  resulting  disabilities.  Fifteen 
years  ago,  surgeons  were  accustomed  to  open  very  widely 
the  abdomen  through  the  oblique  muscles,  to  wash  out 
or  wipe  out  the  cavity,  to  employ  multiple  gauze  drains  ex- 
tending in  all  directions,  and  to  allow  the  whole  wound  to  heal 
without  the  support  of  stitches.  Subsequent  hernicC  were  com- 
mon, extensive  matting  of  the  intestines  frequently  occurred, 
and  constipation  or  actual  intestinal  obstruction  often 
resulted. 

^  Symptoms  pointing  to  disease  of  the  stomach  and  bile 
passages  may  follow  such  an  experience  with  the  appendix 


64  SURGICAL    PROBLEMS. 

as  I  have  described.  Extensive  adhesions  from  an  infection 
low  in  the  abdomen  may  cripple,  kink  or  at  any  time  even 
occlude  the  bile  ducts.  Adhesions  may  drag  upon  and  disturb 
the  normal  relations  of  the  gall  bladder,  stomach,  duodenum 
and  colon. 


DYSPEPSIA. 

Case  21.  On  the  19th  of  June,  1908,  I  was  asked  by 
a  physician  to  see  a  woman,  the  victim  of  a  long-standing 
dyspepsia.  This  patient  was  a  large,  robust  person,  forty- 
three  years  of  age,  who  told  the  following  story :  She  had  been 
perfectly  well  up  to  the  age  of  twenty-three,  when  she  began 
to  notice  occasionally  a  sense  of  oppression  after  eating.  This 
experience  was  more  or  less  periodic,  coming  on  at  first  about 
once  in  every  two  weeks.  She  thought  little  of  it  for  some  two 
or  three  years,  although  the  frequency  of  the  attacks  and  their 
nature  varied.  At  the  end  of  three  years  the  attacks  came 
on  every  two  or  three  days  and  were  of  an  almost  uniform 
character.  About  two  hours  after  eating,  no  matter  what  the 
diet,  she  felt  oppressed,  rather  short  of  breath,  was  flatulent, 
and  experienced  a  gnawing,  or  occasionally  a  knife-like,  pain 
in  the  epigastrium.  This  pain  lasted  almost  without  intermis- 
sion until  the  next  meal.  She  described  it  as  a  hunger  pain, 
which  was  promptly  relieved  by  taking  food.  At  that  time 
such  taking  of  food  would  relieve  the  pain  often  for  several 
days,  always  for  two  or  three  days,  after  which  a  similar 
attack  would  recur.^  At  the  age  of  thirty,  this  patient,  Mrs. 
Winchester,  was  severely  ill  with  typhoid  fever.  During 
her  illness  the  attacks  of  dyspepsia  were  less  pronounced, 
but  upon  her  convalescence  and  thereafter  the  attacks  became 
more  frequent  and  more  severe,  but  were  always  associated 
with  taking  food  and  always  came  some  hours  after  meals. 

In  spite  of  this  chronic  disability,  Mrs.  Winchester  continued 
in  apparent  good  health,  married,  bore  three  children,  and 
though  regarding  herself  as  a  chronic  dyspeptic,  took  a  cheer- 
ful view  of  life  in  general.  At  the  instance  of  her  husband, 
she  saw  a  number  of  competent  physicians,  and  had  many 
routine  examinations  made  of  the  stomach  contents.  The 
report  brought  to  me  was  that  the  motility  of  the  stomach 
was  normal,  that  organ  emptying  itself  completely  of  a  full 
meal  in  from  ten  to  twelve  hours ;  the  acid  content  of  the  stom- 

65 


66  SURGICAL    PROBLEMS. 

ach  was  not  far  from  normal  and  there  was  no  increase  of  hy- 
drochloric acid.  This  lack  of  increase  in  hydrochloric  acid  was 
constantly  doubted  by  the  patient,  and  her  skepticism  seemed 
to  her  justified  by  the  fact  that  several  hours  after  food  she 
had  come  to  experience  a  burning  regurgitation  in  the  throat, 
with  highly  acid  characteristic  taste  in  the  mouth,  the  familiar 
taste  of  gastric  contents.  ^ 

During  the  last  two  years  her  misery  had  greatly  increased. 
She  suffered  frequently  from  blurring  of  vision,  from  obstinate 
frontal  headaches,  from  chronic  constipation,  from  emaciation 
and  general  malaise.  For  such  reasons  she  again  consulted 
her  physician. 

My  physical  examination  of  Mrs.  Winchester  was  interest- 
ing, and  the  findings  were  characteristic.  She  was  a  large, 
well-developed  woman,  somewhat  emaciated  and  with  a  tired 
aspect.  The  sum  total  of  interest  in  her  physical  condition 
was  centered  in  her  abdomen,  which  was  everywhere  slightly 
tender,  but  there  was  marked  tenderness  in  the  median  line, 
about  the  middle  of  the  epigastrium,  where  pressure  caused 
her  to  shrink  anxiously.  Deep  pressure  occasionally  elicited 
a  pain  which,  starting  under  the  fingers,  was  described  as 
darting  through  to  the  back.  The  stomach  was  not  materially 
enlarged,  though  it  was  slightly  prolapsed.  The  analysis  of 
the  gastric  content  showed  a  delayed  motility;  that  is,  the 
stomach  emptied  itself  of  a  full  meal  in  about  fourteen  hours. 
A  trace  of  blood  in  the  stools  was  discovered  by  the  guaiac 
test.  The  analysis  of  the  stomach  content  in  the  main 
differed  little  from  the  normal.^ 

A  lifelong  obstinate  dyspepsia,  associated  with  pain,  nearly 
always  means  some  permanent  organic  derangement.  In  this 
case  I  made  the  diagnosis  of  duodenal  ulcer,  and  advised  an 
operation. 

^  Pain  depending  on  food,  and  coming  on  from  two  to  four 
hours  after  taking  food  is  suggestive  of  some  disturbance 
beyond  or  at  the  pylorus.  This  type  of  pain  has  long  been 
recognized  and  has  commonly  been  regarded  as  due  to  pyloric 
spasm  —  spasm  of  the  irritated  pylorus  at  the  time  of  the 
passage  of  food  through  it,  two  or  more  hours  after  eating. 
Such  pain  is  traditionally  treated  by  giving  alkalies  before 


DYSPEPSIA.  67 

eating,  in  order  to  neutralize  the  acidity  of  the  gastric 
contents. 

^  Patients  generally  make  their  own  diagnosis  of  acid 
dyspepsia  from  the  fact  that  they  regurgitate  hydrochloric 
acicl,  which  scalds  the  ])harynx  and  "  sets  the  teeth  on  edge," 
as  they  say.  Undoubtedly  such  are  the  effects  of  the  regur- 
gitated gastric  contents,  but  the  same  effects  exactly  are  pro- 
duced by  regurgitated  contents  of  the  normal  stomach.  Excess 
of  hydrochloric  acid  cannot  be  detected  by  the  patient  him- 
self, but  must  be  determined  by  careful  chemical  measure- 
ments. 

^  These  findings  are  suggestive  of  various  pathologic  con- 
ditions referred  especially  to  the  stomach,  to  the  duodenum, 
or  to  the  bile  passages,  but  lack  of  peculiarity  in  the  gastric 
analysis,  absence  of  characteristic  attacks  of  gallstone  colic 
and  the  presence  of  pain  coming  on  regularly  two  hours 
after  taking  food,  eliminate  practically  the  question  of  dis- 
ease of  the  stomach  or  of  the  bile  passages.  It  is  to  the 
history  in  this  case  that  we  must  turn  for  help,  and  the 
history  is  absolutely  characteristic;  the  history  is  that  of 
duodenal  ulcer, —  a  long-continued  dyspepsia,  characterized 
by  distress  and  pain  two  to  four  hours  after  taking  food, 
a  normal  acid  content  of  the  stomach  and  a  trace  of  blood 
in  the  stools.  The  classical  signs  of  duodenal  ulcer, —  pro- 
fuse hemorrhage  and  perforation,  with  overwhelming  pain, 
are  late  complications,  for  which  we  should  not  wait. 

Three  days  later  I  operated.  On  opening  down  to  the  duo- 
denum I  found  it  rather  extensively  involved  in  adhesions 
to  the  stomach  and  liver.  These  were  separated  with  some 
difficulty,  when  a  broad,  firm  ulcer  was  discovered  on  the 
anterior  surface  of  the  duodenum,  about  half  an  inch  below 
the  pyloric  vein,  which  marks  the  beginning  of  the  duodenum. 
The  ulcer  was  the  size  of  a  fifty-cent  piece,  with  a  crater  in  its 
center,  which  could  be  demonstrated  easily  by  the  finger 
inverting  the  intestine  from  the  side  opposite  the  ulcer.  I 
performed  gastro-enterostomy  '*  for  proper  stomach  drain- 
age, but  realizing  that  the  partial  pyloric  obstruction  which 
existed  might  recur  at  a  later  period,  I  excised  the  ulcer, 
together  with  the  portion  of  the  gut  in  which  it  was  situated 
and  closed  permanently  the  pylorus.  The  patient  made  an 
excellent  recovery  and  has  been  in  good  health  for  the  past 
eighteen  months. 


68  SURGICAL    PROBLEMS. 

^  In  the  case  of  operating  by  gastroenterostomy  for  duodenal 
ulcer  which  causes  a  partial  pyloric  obstruction,  one  should 
look  to  the  natural  history  of  the  case  after  the  artificial  stoma 
Is  established.  The  artificial  stoma  drains  the  stomach  for 
the  first  weeks  of  convalescence,  the  ulcer  commonly  heals, 
the  resulting  duodenal  and  pyloric  cicatrix  gradually  softens, 
gastric  contents  begin  to  pass  again  by  the  pyloric  outlet, 
and  their  presence  again  commonly  irritates  the  site  of  the 
old  ulcer,  so  that  in  many  cases  a  new  ulcer  develops,  when  the 
state  of  the  patient  is  worse  than  at  first. 


DYSPEPSIA.  69 

Case  22.  On  the  loth  of  December,  1908,  a  lady  of  fifty 
consulted  me,  with  the  statement  that  her  physician  had  sent 
her  to  me  for  an  operation  on  the  shoulder.  She  was  afflicted 
with  a  small  lipoma  on  the  front  of  the  deltoid. 

In  relating  this  case  I  am  reminded  of  an  experience  of 
Moynihan,  who  tells  how  a  man  came  into  his  office  asking  to 
be  operated  upon  for  hernia.  The  man's  color  was  so  bad 
and  he  had  an  anemia  so  pronounced  that  Moynihan  immedi- 
ately suspected  some  form  of  internal  hemorrhage,  and  his 
suspicion  was  verified  by  subsequent  investigation. 

My  patient  also  impressed  me  as  being  the  victim  of  some 
form  of  hemorrhage.  As  she  entered  my  office  my  first  im- 
pression was  that  she  was  a  tall,  well  set-up,  but  somewhat 
emaciated  woman.  I  Immediately  recognized  further  some 
considerable  degree  of  anemia.  When  she  described  and  ex- 
hibited her  fatty  tumor  I  was  prompted  to  disregard  it  for 
the  moment  and  to  ask  her  further  about  her  general  health. 
She  said  that  she  had  been  losing  blood  occasionally,  in  small 
amounts,  from  a  troublesome  hemorrhoid.  This  proved  to 
be  a  slight  matter,  and  certainly  did  not  account  for  the  degree 
of  anemia  which  she  presented.  Her  past  history  was  not 
uninteresting.  She  had  been  married  some  thirty  years,  and 
was  the  mother  of  four  children.  Up  to  the  age  of  thirty  she 
was  sound  and  active.  At  that  time  she  had  a  long  struggle 
with  a  disordered  set  of  teeth,  which  were  irregular,  misshapen 
and  soft,  given  easily  to  decay.  As  a  result  she  found  great 
difficulty  in  chewing  her  food,  and  for  some  years  was  in  the 
habit  practically  of  bolting  all  solid  food.  Consequently, 
at  about  the  age  of  thirty-two,  she  began  to  be  troubled  with 
an  obstinate  chronic  dyspepsia,  punctuated  especially  by 
a  heavy  feeling  in  the  epigastrium,  by  chronic  constipation, 
by  occasional  "  bilious  attacks  "  and  by  frequent  headaches. 
She  had  been  the  rounds  of  the  specialists.  Her  eyes  had  been 
overhauled;  the  neurologists  had  dismissed  her;  the  internists 
had  told  her  that  her  stomach  was  not  at  fault ;  and  the  sur- 
geons had  found  nothing  in  her  abdomen  calling  for  operation. 
From  time  to  time  she  had  been  greatly  Improved  by  courses 
of  Carlsbad  salts  and  copious  dosing  with  bicarbonate  of  soda; 
lavage  of  the  stomach  also  relieved  her  a  great  deal.    When 


70  SURGICAL    PROBLEMS. 

about  forty  years  of  age  her  misery  was  increased  by  occasional 
attacks  of  pain  in  the  right  side  of  the  epigastrium,  pain  extend- 
ing frequently  into  the  hypochondrium  and  along  the  border 
of  the  ribs.  At  that  time  she  was  thought  to  have  a  chronic 
appendicitis,  and  her  appendix  —  not  materially  damaged  — 
was  removed.  This  did  not  help  her.  It  was  said  that  at 
the  time  of  the  operation  nothing  wrong  could  be  found  in 
the  region  of  the  bile  passages  and  stomach.  Shortly  after 
this  operation,  while  her  former  symptoms  continued  una- 
bated, she  began  to  observe  a  new  symptom,^ —  definite,  daily 
recurring  attacks  of  distress  and  actual  pain  in  the  epigastrium 
about  three  hours  after  taking  food.  Although  these  attacks 
were  recurring  and  were  definite,  they  were  never  severe,  and 
always  passed  off  with  the  succeeding  meal.  She  had  been 
told  that  she  had  an  excess  of  acid  in  the  stomach,  and  for 
the  correction  of  this  she  was  advised  constantly  to  take 
bicarbonate  of  soda  before  meals.  Such  dosage  with  bicar- 
bonate of  soda  certainly  relieved  her,  and  when  such  relief 
was  long  delayed  she  was  accustomed  to  wash  out  her  own 
stomach,  which  promptly  checked  her  bad  symptoms.  Had 
she  had  bleeding  from  the  rectum?  I  asked.  Yes,  frequently; 
slight  bleeding  from  a  hemorrhoid  after  movements  of  the 
bowels;  no  other  obvious  blood,  though  frequently,  sometimes 
daily,  the  movements  of  the  bowels  would  be  dark  colored, 
almost  black,  a  condition  she  supposed  due  to  the  medicine 
she  took,  for  she  had  long  been  in  the  habit  of  taking  courses 
of  iron  on  account  of  her  anemia.^ 

^  Here  is  an  extremely  interesting  train  of  symptoms, 
which  suggest  again  a  variety  of  disorders, —  gastric  ulcer, 
duodenal  ulcer,  gallstone  disease,  appendicitis,  some  rectal 
disturbance,  polypi  or  hemorrhoids,  and  the  frequently 
associated  ptosis  of  the  intestines.  Gastric  ulcer  rarely,  if 
ever,  causes  bleeding  into  the  intestine  sufficient  to  color  the 
stools;  the  pain  of  gastric  ulcer  follows  immediately  after 
taking  food.  Duodenal  ulcer  may  give  rise  to  constant  slight 
hemorrhage,  sufficient  to  color  the  stools  black,  while  the 
pain  of  duodenal  ulcer  follows  two  to  four  hours  after  taking 
food.  Gallstone  disease  in  no  way  modifies  the  character  of 
the  stools,  except  to  leave  them  clay  colored  in  the  case  of  an 
obstructed  common  duct ;  the  pain  of  gallstone  disease  is  severe 


DYSPEPSIA.  71 

but  infrequent,  and  bears  little  or  no  relation  to  food.  Ap- 
pendicitis influences  the  bowels  in  no  way,  except  to  encourage 
constipation,  but  the  pain  of  appendicitis  may  simulate  the 
pain  of  almost  any  other  diseased  abdominal  organ.  Disease 
of  the  rectum  is  associated  with  constipation,  and  if  accom- 
panied by  bleeding  that  bleeding  appears  as  fresh  blood  in  the 
stools;  rectal  disease  is  rarely  associated  with  epigastric  pain. 

1  made  a  diagnosis  of  bleeding  duodenal  ulcer,  founding 
my  belief  on  the  periodicity  of  the  attacks  of  pain,  their 
occurrence  three  hours  after  taking  food,  and  the  presence 
of  blood  in  the  stools,  which  was  proved  abundantly  by  mi- 
croscopic examination  and  by  the  guaiac  test. 

At  operation  I  discovered  an  old  ulcer,  situated  mainly  on 
the  posterior  surface  of  the  duodenum  and  about  as  large 
as  a  silver  half-dollar.  It  did  not  constrict  particularly  the 
lumen  of  the  gut.  Ithad  wide  indurated  edges,  ^  with  a  terraced 
interior  and  a  large  surface  of  granulations,  among  which 
was  one  small  venule  which  seemed  constantly  to  be  oozing 
blood.  I  resected  that  portion  of  the  gut,  closed  the  pylorus 
and  completed  the  operation  by  gastro-enterostomy.^ 

The  patient  made  a  tedious  recovery,  owing  probably  to 
her  long-standing  anemia,  but  she  is  now  greatly  improved, 
and,  though  still  somewhat  anemic,  regards  herself  as  well. 

2  In  connection  with  the  healing  of  duodenal  ulcers,  sur- 
geons have  discussed  the  possibility  of  malignant  disease 
developing  on  the  site  of  such  ulcers.  Malignant  disease 
rarely  develops  from  ulcer  of  the  duodenum;  it  develops 
commonly  from  ulcer  of  the  pyloric  area  of  the  stomach; 
but  in  the  great  statistics  of  Mayo  and  of  Moynihan  cancer 
developing  upon  duodenal  ulcer  has  been  found  in  between 
two  and  three  per  cent  only  of  the  cases. 

^  These  cases  of  chronic  duodenal  ulcer  are  not  common  in 
women ;  the  usual  victims  are  men.    The  reason  is  not  obvious. 


']2  SURGICAL    PROBLEMS. 

Case  23.  John  Conover,  an  active  commercial  traveler 
of  Orange,  N.  J.,  consulted  me  on  the  19th  of  November, 
1909.  He  was  thirty-nine  years  old  and  a  hard  drinker.  He 
smoked  twenty  cigarettes  a  day  and  half  a  dozen  cigars.  He 
limited  his  drinking  to  the  evening,  and  complained  that  his 
night's  sleep  was  often  disturbed  in  consequence  of  such 
limitation.  Two  bibulous  companions  who  brought  him  to 
me  shook  their  heads  solemnly  over  his  sad  condition.  Mr. 
Conover  was  the  dyspeptic  hero  of  their  little  coterie.  There 
were  gloomy  whisperings  of  the  "  water  wagon."  Out  of  a 
tangled  mass  of  gossip,  assertion  and  contradiction,  in  which 
the  three  friends  assisted  each  other,  I  drew  the  following  tale : 

Mr.  Conover  had  begun  his  alcoholic  career  at  the  age  of 
seventeen,  when  he  was  an  office  boy.  As  he  rose  in  the  ranks 
he  became  a  valued  salesman  on  the  road,  and  for  many  years 
had  drawn  a  good  salary.  At  the  age  of  twenty-five  he  con- 
tracted syphilis,  but  now  regarded  himself  as  long  cured. 
He  had  never  married.  At  the  age  of  thirty,  that  is,  about  nine 
years  before  his  visit  to  me,  he  developed  rapidly  what  Moynl- 
han  has  taught  us  to  look  upon  as  the  fundamental  symptom 
of  duodenal  ulcer, —  distress,  fullness  and  pain  two  or  three 
hours  after  taking  food.  This  symptom  in  Mr.  Conover's 
case  was  characteristic,  was  pronounced,  and  had  visited 
him  after  nearly  every  meal  for  five  or  six  years.  He  claimed 
that  for  a  long  time  it  was  relieved  by  drinking  straight 
whiskey, —  doubtless  a  fact.  Self-induced  vomiting  also 
relieved  him,  and  the  copious  drinking  of  soda  water  in  the 
morning.  Nevertheless,  the  pains  recurred.  He  was  frequently 
subject  to  belchings  and  eructations  of  the  stomach's 
contents,  always  very  bitter.  He  thought  that  he  had  an 
acid  stomach,  due  to  lack  of  exercise  and  to  improper  food. 
Six  months  before  I  saw  him  he  experienced  a  sudden  prostrat- 
ing pain  in  the  epigastrium,  which  sent  him  to  the  hospital 
where  a  diagnosis  of  bleeding  duodenal  ulcer  was  made.  At 
that  time  he  had  both  vomited  blood  and  passed  blood,  but 
not  in  large  amounts.  His  condition  at  the  time  of  his  visit 
to  me  was  much  as  it  had  been  before  the  perforation,  and  that 
condition  was  deplorable,^ 

I  sent  this  man  to  the  hospital  at  once,  with  the  purpose 


DYSPEPSIA.  73 

of  keeping  him  there  for  a  couple  of  days  and  then  operating. 
That  very  night,  as  he  lay  in  the  hospital,  his  ulcer  perforated. 
He  was  seized  with  the  classical  symptoms,—  agonizing  pros- 
trating pain,  intense  rigidity,  a  subnormal  temperature,  a 
pulse  at  first  undisturbed,  later  rising  with  the  temperature, 
becoming  soft,  compressible  and  rapid,  while  the  fever  reached 
103°  Fahrenheit.  I  was  called  and  operated  at  once.  I  found 
the  belly  full  of  liquid  food  and  exudate,  collected  mainly 
in  the  right  iliac  fossa  and  in  the  pelvis.  The  ulcer  was  upon 
the  anterior  surface  of  the  duodenum,  and  was  about  the  size 
of  a  fifty-cent  piece.  The  opening  in  the  ulcer  would  admit 
an  instrument  the  size  of  a  slate  pencil. 

I  infolded  ^  and  closed  the  wound  in  the  duodenum,  washed 
out  the  belly,  closed  the  epigastric  wound  and  inserted  a 
drain  above  the  pubes,  reaching  down  to  the  bottom  of  the 
pelvis.  I  conducted  the  after-treatment  on  the  principle 
instituted  by  Murphy,  placing  the  patient  in  the  semi-upright 
position  and  introducing  a  continuous  trickling  stream  of  salt 
solution  into  the  rectum.  I  was  surprised  and  gratified  with 
the  result. 

After  a  stormy  week,  in  which  he  was  threatened  with  de- 
lirium tremens,  the  patient  rallied,  the  diffuse  peritonitis 
subsided,  the  wound  healed,  and  he  left  the  hospital  a  chas- 
tened man  at  the  end  of  three  weeks.  He  reformed  his  habits 
and  is  now  relatively  well. 

^  Hemorrhage  and  perforation  are  late  complications  of 
duodenal  ulcer,  as  I  have  said.  The  physician  and  the  sur- 
geon should  never  wait  for  their  development.  In  the  words 
of  Moynihan:  "  Of  nothing  concerned  with  the  relationship 
between  altered  structure  and  altered  function  am  I  so  con- 
vinced as  that  symptoms  such  as  I  have  portrayed  [the  early 
symptoms  of  distress  some  hours  after  eating]  owe  their  origin 
to  and  are  dependent  for  their  periodic  repetition  upon  a 
chronic  duodenal  ulcer.  A  description  of  these  symptoms 
is  to  be  met  with  in  most  of  the  text-books  of  medicine  under 
the  caption  of  '  hyperchlorhydria  '  or  '  acid  gastritis,'  and  the 
belief  that  these  words  are  a  sufficient  diagnosis  is  very  general. 
After  giving  a  diagnosis  of  duodenal  ulcer,  I  am  not  infre- 
quently met  with  the  objection  that  the  patient's  symptoms 
are  indications  of  nothing  more  than  persistent  hyperchlor- 


74 


SURGICAL    PROBLEMS. 


hydria.  This  is  the  medical  term  for  the  surgical^  condition 
duodenal  ulcer.  The  symptoms  of  acid  dyspepsia,  if  they  are 
intractable  and  recurrent,  are  due  to  the  demonstrable  lesion 
duodenal  ulcer." 

2  The  treatment  of  acutely  perforating  ulcer  is  much  in  de- 
l,2^te, —  whether  to  infold  the  ulcer  merely,  or  to  perform 
gastro-enterostomy  at  the  same  time.  My  experience  leads 
me  to  believe  that  gastro-enterostomy,  if  performed  at  all, 
had  best  be  deferred  for  a  few  weeks  or  months,  that  the  ulcer 
may  have  a  chance  to  heal  and  that  the  patient's  subsequent 
condition  may  be  studied.  The  mere  infolding  of  the  ulcer 
suffices  in  a  great  many  cases.  If,  however,  subsequent  symp- 
toms develop,  and  it  becomes  clear  that  a  cure  is  not  estab- 
lished, then  a  secondary  gastro-enterostomy  may  usually 
be  performed  with  safety  and  success.  If,  however,  the 
infolding  of  the  ulcer,  as  occasionally  happens,  involves  an 
almost  complete  closure  of  the  duodenum,  gastro-enterostomy 
must  be  performed  as  a  primary  operation,  should  the  patient's 
condition  permit. 


GYNECOLOGY. 

Case  24.  Mrs.  Lufkin,  the  wife  of  a  naval  officer,  consulted 
me  on  the  29th  of  April,  1908.  She  had  come  to  Boston 
to  seek  the  help  of  the  Emmanuel  health  class,  but  was 
advised  after  reaching  here  that  she  might  better  consult  a 
physician.  She  was  a  woman  of  thirty-one,  who  appeared 
much  younger  than  her  age.  She  was  vigorous,  handsome, 
intelligent  and  quick-witted,  given  to  introspection,  and  with 
a  long  history.  Before  her  marriage,  even,  this  lady  had  suf- 
fered from  numerous  ailments,  which  she  described  as  excrucia- 
ting. She  had  had  extremely  painful  menstruation  as  a  girl, 
and  regarded  herself  as  a  pronounced  dyspeptic  at  the  age 
of  twenty,  when  she  married.  Since  that  time  her  symptoms 
had  persisted  and  she  had  fallen  upon  various  other  ailments, — 
flatulence  and  pain  after  taking  food;  chronic  constipation 
of  a  most  distressing  character;  frequent  headaches  and  blur- 
ring of  vision ;  while  within  the  last  two  years  she  had  developed 
a  persistent,  nagging  cough,  which  awoke  her  at  night,  and  for 
which  no  relief  was  forthcoming.  The  birth  and  care  of  her 
baby,  seven  years  before  I  saw  her,  had  made  no  particular 
impression  upon  her  health.  She  told  me  casually  that  she 
had  received  the  usual  perineal  tear  in  child-birth,  but  that 
this  was  repaired  a  year  later  and  had  not  troubled  her  since. 
Four  years  before  I  saw  her  a  surgeon  opened  her  abdomen 
with  the  idea  of  removing  gallstones.  He  found  no  gallstones 
and  therefore  removed  her  left  ovary,  without  any  special 
reason,  so  far  as  Mrs.  Lufkin  was  aware.  At  the  same  time, 
she  stated,  he  had  proposed  hysterectomy,  as  her  uterus  was 
said  to  be  studded  with  small  myomatous  growths.  She 
thought  that  such  a  uterine  affliction  was  probable,  inasmuch 
as  she  never  had  been  pregnant  since  the  birth  of  her  only  child. 

This  congeries  of  symptoms  suggests,  in  the  first  place, 
that  much  abused  word  "  neurasthenia,"  and  a  state  of  mental 
and  nervous  instability ;  but  on  studying  the  physical  condition 
of  the  woman  one  felt  that  there  might  well  be  some  anatomical 

75 


76  SURGICAL    PROBLEMS. 

cause  behind  her  misery.  Her  throat  and  chest  were  not  ab- 
normal, her  eyes  were  sound,  her  abdomen  was  not  pecuUar; 
there  was  no  visceral  ptosis;  there  were  no  tender  spots, 
even  over  the  appendix;  and,  most  important  of  all,  from  the 
point  of  view  of  etiology,  her  previous  operation  had  left 
no  permanent  impression  on  her  mind. 

My  examination  of  the  pelvis  revealed  a  definite  derange- 
ment. There  was  a  wide  tear  of  the  perineum  down  to  the 
sphincter  ani  muscle;  there  was  a  slight  cystocele,  a  marked 
rectocele,  a  pronounced  endometritis,  with  considerable 
leucorrhea,  and  the  uterus  was  retrocessed,  enlarged  to  the 
size  of  a  man's  closed  fist  and  studded  with  numerous  small 
growths,  presumably  myomata. 

The  problem  which  this  case  presented  to  the  surgeon 
was  not  so  simple  as  at  first  it  had  appeared.  One  says  at 
once  that  the  obvious  indications  were  to  repair  the  perineum 
and  to  remove  the  uterus,  but  we  should  remember  that  this 
uterus  was  not  causing  any  considerable  trouble;  there  were 
no  catamenial  disturbances  or  unusual  flowings,  in  spite  of  the 
fact  that  all  presumptive  evidence  assured  us  that  the  myo- 
mata had  existed  for  four,  five  or  more  years.  Moreover,  the 
patient  was  most  anxious  to  have  children,  and  shrank  from 
the  thought  of  hysterectomy. 

I  operated  conservatively,  therefore,  repairing  broadly 
the  perineum  by  a  flap-splitting  operation,  which  allows  the 
surgeon  to  bring  together  strongly  the  torn  levator  ani  muscle 
and  sustains  the  sagging  bladder  and  rectum.  I  then  opened 
the  abdomen  from  above,  drew  up  the  uterus  and  removed 
from  beneath  its  serous  surface  some  seven  small  myomata, 
varying  in  size  from  a  peanut  to  an  English  walnut.  The  re- 
moval of  these  little  growths  reduced  the  uterus  to  about  its 
normal  size.  I  suspended  it  by  drawing  the  round  ligaments 
over  the  exposed  recti  muscles  and  stitching  them  together 
in  the  middle  line.  I  removed  also  an  adherent  and  twisted 
appendix. 

Mrs.  Lufkin  made  an  excellent  convalescence;  her  various 
nervous  symptoms  were  greatly  benefited  by  the  operation 
and  a  three  weeks'  rest  in  bed.  On  June  19,  six  weeks 
after  the  operation,  she  reported  to  me  as  "  free  from  all 


GYNECOLOGY.  77 

symptoms  and  feeling  extremely  well."  Shortly  afterward 
she  went  West,  and  I  did  not  hear  from  her  again  until  July, 
19 10,  when  she  wrote  to  me  that  she  was  in  San  Francisco, 
about  to  go  to  New  York,  and  that  she  was  three  months  preg- 
nant. A  month  later  I  received  from  her  in  New  York  a  har- 
rowing letter,  describing  her  mischances  on  that  railway 
journey.  Two  days  after  leaving  San  Francisco  she  was  taken 
in  labor  and  had  a  miscarriage  on  the  train.  Eventually  she 
arrived  in  New  York  somewhat  depressed  in  spirits  but  appar- 
ently in  sound  physical  health  and  hopeful  for  the  future. 


78  SURGICAL    PROBLEMS. 

Case  25.  There  is  a  strong  temptation  for  a  physician 
who  has  long  been  socially  acquainted  with  a  particular  indi- 
vidual, to  assume  that  he  knows  more  of  that  individual's 
general  health  than  actual  experience  justifies.  This  tempta- 
tion is  illustrated  by  the  case  of  Mrs.  Street,  who  consulted 
me  on  the  15  th  of  October,  1908.  She  was  forty-five  years 
old,  and  I  had  known  her  as  a  neighbor  and  had  seen  her 
almost  daily,  for  some  fifteen  years.  During  that  period, 
and  at  the  age  of  thirty-three,  she  married  and  bore  two 
children.  She  was  a  bright,  active,  intelligent  woman,  who 
told  me  on  the  occasion  of  her  consultation  that  she  never  had 
been  ill  except  in  connection  with  child-bearing.  When  her 
first  baby  was  born  her  perineum  was  badly  torn,  and  was 
repaired  secondarily  some  ten  years  before  I  saw  her.  She 
believed  that  at  the  same  time  a  repair  of  the  cervix  was  made. 
As  a  result  of  her  child-bearing,  though  as  she  believed  as  a 
result  of  her  operation,  she  had  suffered  from  increasingly  poor 
health  during  the  past  five  years.  There  was  constant  "  dis- 
tress "  low  in  the  back,  while  her  menstrual  periods  occurred 
every  five  weeks  only,  instead  of  every  four  weeks  as  formerly; 
her  endurance  also  was  diminished;  and  she  stated  that  her 
physician  said  there  was  a  tumor  of  the  uterus  which  should 
be  removed.  On  the  other  hand,  her  appetite  was  good,  and 
she  said  that  all  her  functions,  except  those  mentioned,  were 
normal. 

Mrs.  Street  appeared  to  be  a  middle-aged  woman  in  vigor- 
ous health,  plump,  ruddy  and  spirited.  She  was  extremely 
intelligent,  and  submitted  to  a  discussion  of  her  case  without 
imparting  to  me  any  unnecessary  Information. 

On  examining  the  perineum  I  found  It  extensively  torn  to 
the  sphincter  ani,  the  uterus  to  be  in  a  condition  of  retrocession 
and  to  be  slightly  enlarged.  Evidently  a  repair  of  the  cervix 
had  been  made,  but  this  repair  could  not  have  been  successful, 
for  the  cer^^Ix  was  widely  torn  and  was  bridged  across  the  center 
of  the  OS  by  a  strip  of  tough  scar  tissue.  The  cervix  was 
greatly  thickened,  also,  and  suggested  the  possible  presence  of 
a  beginning  malignant  disease. 

I  regarded  Mrs.  Street  as  an  extremely  good  surgical  risk, 
and  advised  an  amputation  of  the  cervix,  a  suspension  of  the 


GYNECOLOGY.  79 

Uterus  and  a  repair  of  the  perineum.  She  entered  the  hospital 
on  the  loth  of  November  for  the  operation,  and  on  the  day  of 
her  entrance  appeared  fatigued  and  unhappy.  She  said  she 
did  not  feel  very  well,  but  I  could  find  nothing  materially 
wrong  with  her  after  a  careful  physical  examination;  her 
temperature  was  normal;  her  pulse  70;  there  was  nothing 
abnormal  to  be  discovered  in  the  chest  or  throat,  and  an  ab- 
dominal examination  was  negative.  I  assumed,  therefore, 
that  her  feeling  of  weakness  and  discomfort  was  probably 
due  to  her  anxiety  about  the  operation. 

She  was  carefully  anesthetized  by  a  special  expert,  who  gave 
her  nitrous  oxide  followed  by  ether.  I  examined  the  cervix, 
which,  on  trimming  off  the  bridge  of  scar  tissue  over  the  os, 
showed  some  "  erosions  "  only;  accordingly  I  refrained  from 
amputating  it,  but  repaired  it  carefully.  I  repaired  the 
perineum  also,  a  tedious  matter,  but  of  no  special  difficulty. 
On  opening  the  abdomen  I  discovered  that  the  main  cause 
for  the  patient's  discomfort  was  a  mass  of  adhesions  around 
an  old  chronically  inflamed  right  tube  and  ovary.  These 
adhesions  were  not  dense  and  did  not  fix  firmly  the  organs, 
which  accounted  probably  for  the  fact  of  my  not  having  dis- 
covered them  before  the  operation.  I  removed  the  obliterated 
tube  and  the  disorganized  ovary,  and  took  out  the  adjacent 
appendix.  The  operation  was  completed  by  suspending  the 
uterus,  and  the  pelvis  was  left  clean  and  dry.^ 

Mrs.  Street  rallied  slowly  from  the  operation,  and  appeared 
to  be  in  unusual  discomfort  that  afternoon.  Her  evening 
temperature  was  100°,  her  pulse  soft  and  rapid,  registering  no 
at  four  o'clock.  She  passed  a  wretched  night,  without  fall 
of  temperature,  her  morning  record  being:  temperature  100° 
and  pulse  112;  while  towards  the  evening  of  that  day  her  tem- 
perature reached  102°.  At  this  time  I  examined  her  carefully 
and  found  bronchial  breathing  at  the  apex  of  the  right  lung. 
The  abdomen  was  flat  and  there  was  no  particular  tenderness 
or  discomfort  about  the  wounds.  She  continued  to  fail 
during  that  night,  her  morning  temperature  the  third  day 
being  102°,  while  a  consolidation  of  the  lung  from  a  pronounced 
pneumonia  had  developed.  She  responded  properly  to  free 
catharsis  and  the  abdomen  was  flat  and  in  good  condition. 


80  SURGICAL   PROBLEMS. 

Towards  night  on  the  third  day  she  sank  rapidly,  and  in  the 
evening  her  temperature  reached  104°,  with  pulse  150  and 
respiration  40.     She  died  at  eight  o'clock.^ 

^  I  long  ago  ceased  to  regard  these  operations  as  the  trifling 
affairs  which  we  once  thought  them.  Repair  of  the  perineum 
plus  abdominal  section  and  the  removal  of  diseased  tubes  is 
a  serious  matter.  Many  women  react  badly  after  this  opera- 
tion, perhaps  because  long  ill-health  has  reduced  their  resisting 
powers.  Subsequent  sepsis  is  not  unknown,  even  after  the 
greatest  care  on  the  part  of  the  operator ;  and  on  more  than  one 
occasion  I  have  seen  pneumonia  follow  the  operation.  I  need 
scarcely  remind  the  experienced  reader,  moreover,  that  this 
digging  out  of  adhesions  from  the  pelvis  is  frequently  followed 
by  slow  oozing  and  occasionally  by  secondary  hemorrhage. 
In  the  course  of  the  last  twenty  years  I  have  myself  lost  two 
patients  from  hemorrhage  of  the  ovarian  artery,  the  ligature 
having  slipped  off  the  stump.  Doubtless  every  surgeon  can 
recall  a  similar  experience. 

^  Such  a  surgical  calamity  as  I  have  described,  while  it  puts 
a  man  on  his  mettle,  suggests  a  number  of  complications 
which  he  might  have  met  and  a  number  of  measures  which  he 
might  have  taken.  In  the  case  of  Mrs.  Street  there  was  no 
reason  to  suspect  any  pulmonary  disturbance;  indeed,  I  ex- 
amined her  lungs  before  the  operation  and  found  nothing 
wrong.  It  has  long  been  my  habit  to  provide  against  a  so- 
called  ether  pneumonia  by  thoroughly  disinfecting  the  nose 
and  throat  with  albolene  and  by  sending  patients  to  the  opera- 
ting room  clad  in  a  warm  "  ether  jacket  ";  nevertheless,  I 
feel  more  and  more  certain,  as  I  give  closer  attention  to  the 
subject  of  anesthesia,  that  ether  is  a  decided  depressant  of 
the  vital  forces.  Two  years  ago  I  was  not  following  my  present 
routine  of  carrying  suitable  patients  through  the  operation 
with  nitrous  oxide  and  oxygen  only.  I  believe  to-day  that  the 
use  of  that  anesthetic  would  have  been  wise  in  the  case  of  Mrs. 
Street.  Every  case  of  ether  pneumonia  teaches  its  lesson, 
and  while  the  condition  is  rare,  it  is  well  for  the  surgeon 
and  the  general  practitioner  to  bear  it  in  mind  as  one  of  the 
shocking  and  possible  outcomes  of  an  operation  ordinarily 
viewed  with  equanimity. 


GYNECOLOGY.  8 I 

Case  26.  Some  two  years  ago  there  came  into  my  office 
at  the  end  of  a  tiresome  day  a  tail,  stout,  red-faced  woman, 
who  announced  vigorously  that  her  name  was  Mrs.  Grand, 
that  she  was  fifty-seven  years  old  and  that  she  had  no  family 
physician.  I  thoughtlessly  asked  her  one  of  my  favorite 
questions,  "What  is  your  problem?"  She  replied,  "/  am 
your  problem."  The  conversation  thus  auspiciously  begun 
continued  through  a  half  hour  of  intricate  navigating,  and  I 
am  not  sure  to  this  day  whether  or  not  I  sounded  the  bottom 
of  her  difficulty.  She  was  a  person  averse  to  communica- 
tion and  suspicious  of  cross-examination.  She  preserved 
throughout  our  interview  an  attitude  of  cold  reserve,  while  she 
exercised  her  critical  faculty  by  demanding  the  exact  definition 
of  every  term  I  used.  At  length,  after  wallowing  in  a  sea  of 
misunderstanding,  I  emerged  with  certain  facts  more  or  less 
clearly  determined.^ 

I  gathered  from  Mrs.  Grand  that  she  had  suffered  through 
life  from  various  minor  troubles,  —  from  a  supine  and  unsuc- 
cessful husband;  from  an  ungrateful  daughter;  from  chronic 
constipation;  from  a  suspicious  temper;  from  measles,  whoop- 
ing cough  and  scarlatina  in  childhood ;  from  an  uncongenial 
boarding-school  and  from  chronic  dyspepsia.  At  the  age  of 
twenty-one  she  married,  and  subsequently  produced  four  chil- 
dren, at  intervals  of  two  and  three  years,  her  youngest  child 
being  twenty-four  years  of  age  at  this  time.  During  the 
period  of  her  child-bearing  she  was  actively  concerned  with 
many  interests  outside  of  the  nursery ;  in  questions  of  woman 
suffrage,  and  in  women's  clubs  especially;  in  all  of  which  she 
received  little  or  no  support  from  her  husband.  As  a  result 
she  assured  me  that  her  life  was  made  extremely  hard  and  her 
previous  condition  of  ill-health  aggravated.  Her  four  labors 
were  difficult,  all  of  them  being  assisted  by  forceps.  The 
children  were  large  and  healthy,  however,  and  had  grown  up 
with  little  help  from  physicians.  At  the  age  of  forty  she 
suffered  from  a  long  attack  of  typhoid  fever,  from  which  she 
was  nearly  two  years  in  convalescing.  At  forty-eight  she  passed 
the  menopause,  and  from  that  time  she  dated  her  present 
illness,  which  indeed  appeared  to  be  but  an  exaggeration  of 
previous  discomforts. 


82  SURGICAL    PROBLEMS. 

I  summed  up  her  condition  and  symptoms  as  follows :  Dull 
contempt  for  the  opinions  of  other  persons;  a  harsh,  irascible 
temper ;  a  desire  to  dominate  every  situation ;  general  abdomi- 
nal pain  and  distress  after  all  food  except  liquids;  frequent 
sub-occipital  headaches ;  occasional  slight  loss  of  blood  from 
the  bowel,  and  chronic  constipation.^ 

^  I  have  been  at  some  pains  to  describe  this  interview 
because  it  illustrates  the  occasional  difficulties  which  are 
encountered  in  arriving  at  a  patient's  history.  There  are 
two  exasperating  types  of  professional  interviews;  one  is 
that  in  which  the  patient  pours  out  a  flood  of  uncorrelated 
information  which  has  little  or  no  bearing  on  her  case;  the 
other  is  that  more  rare  one  in  which  the  patient  assumes  an 
attitude  of  distrust  and  reserve,  acknowledging  symptoms 
with  a  question  and  leaving  the  surgeon  to  infer  that,  after 
all,  he  may  be  mistaken  in  his  conclusions. 

^  The  examiner  must  not  be  misled  by  peculiarities  of  man- 
ner and  temperament.  Remember  that  numerous  extrinsic 
and  psychic  causes  may  lead  to  such  peculiarities.  There 
can  be  no  doubt  of  the  truth  which  lay  in  the  old  notion 
that  "  chronic  dyspepsia  "  is  a  cause  of  chronic  irritability. 
This  woman's  mental  attitude  was  so  peculiar  that,  while 
I  was  unable  to  make  a  diagnosis  of  positive  mental  disorder, 
I  felt  convinced  that  some  physical  disturbance  must  underlie 
her  moods. 

Somewhat  to  my  surprise,  a  physical  examination  was  not 
refused,  and,  again  to  my  surprise,  this  revealed  a  positive 
disorder  of  which  I  had  little  suspected  the  extent.  The  eyes, 
throat,  nose  and  chest  were  negative ;  the  abdomen,  while  ten- 
der in  the  region  of  the  appendix,  was  in  no  other  way  peculiar; 
but  on  examining  the  pelvis  I  discovered  a  widely  torn  peri- 
neum, arectocele  and  a  descent  of  the  uterus,  which  projected 
well  between  the  vulva  and  carried  with  it  almost  the  whole 
of  the  bladder.  The  unhappy  woman  had  allowed  me  to  cross- 
question  her  for  half  an  hour  to  no  purpose,  while  bearing  with 
her  this  distressing  and  exaggerated  lesion. 

It  is  needless  to  describe  the  nature  of  the  treatment  insti- 
tuted further  than  to  state  that  I  repaired  carefully  the  peri- 
neum and  hung  up  the  uterus,  after  splitting  it  in  the  manner 
first  proposed  by  Crile. 


GYNECOLOGY.  83 

The  pelvic  disability  was  completely  cured,  and  the  train 
of  symptoms  to  which  the  patient  had  actually  confessed 
was  also  much  modified;  her  chronic  dyspepsia  was  greatly 
improved,  especially  her  headaches  were  banished ;  and  one 
of  her  daughters  confided  to  me  later  that  her  mother's  temper 
and  disposition  were  much  changed  for  the  better. 


.     THE   HEAD. 

Case  27.  On  the  15th  of  June,  1905,  while  Mr.  F.  H. 
Fox,  of  Philadelphia,  was  motoring  in  the  neighborhood  of 
Boston,  with  a  company  of  cheerful  companions,  about  mid- 
night his  car,  running  at  a  high  rate  of  speed,  suddenly  left 
the  road  and  "  turned  turtle."  Mr.  Fox  was  thrown  out 
violently  and  landed  on  his  head.  He  was  picked  up  uncon- 
scious and  taken  to  a  neighboring  cottage  hospital.  I  was 
called  to  see  him  twenty-four  hours  later.  When  I  reached 
the  patient  he  was  still  unconscious,  as  he  had  been  since  the 
accident,  and  was  surrounded  by  a  bevy  of  female  relatives, 
who  rendered  an  examination  and  proper  discussion  of  the 
case  extremely  difficult. 

My  first  observations  of  the  patient  were  these :  He  was  a 
man  of  thirty-one,  apparently  in  robust  health,  who  was  said 
to  have  been  always  well.  He  lay  in  bed,  breathing  sterto- 
rously.  It  was  reported  that  his  morning  temperature  had 
been  103.6°  and  pulse  100.  When  I  saw  him  in  the  evening 
his  temperature  was  101°,  his  pulse  120  and  his  respirations  15. 
He  could  be  roused  to  a  muttering  reply  by  loud  questioning 
and  it  was  stated  that  his  condition  had  improved  slightly 
during  the  day.  All  of  his  reflexes  were  normal,  but  there  was 
a  slight  divergent  strabismus.  There  were  sundry  bruises 
on  the  body  and  marked  ecchymoses  in  the  right  temporal 
region  and  over  the  right  loin.  I  could  detect  no  other  out- 
ward lesions.^ 

In  the  case  of  Mr.  Fox  the  general  symptoms,  aside  from 
the  semi-consciousness,  were  not  specially  marked.  The  man 
was  evidently  in  some  pain  from  headache.  He  had  had  no 
vomiting,  however,  and  his  eye-grounds  showed  no  evidence 
of  irritation  to  the  optic  nerves.  The  labored  breathing,  how- 
ever, and  a  marked  congestion  of  the  head,  suggested  compres- 
sion at  the  base,  and  the  slight  divergent  strabismus  rein- 
forced the  suggestion;  but  there  was  no  evidence  whatever 

85 


86  SURGICAL    PROBLEMS. 

of  cortical  damage,  nor  of  special  pressure  upon  the  efferent 
nerves. 

In  these  cases,  if  time  enough  be  allowed,  the  range  of  tem- 
perature gives  us  extremely  important  prognostic  evidence. 
A  normal  temperature  is,  of  course,  favorable;  a  steadily  rising 
temperature  is  most  unfavorable;  a  temperature  suddenly 
elevated  and  then  gradually  falling  again  is  favorable.  Mr. 
Fox  had  had  a  high  temperature,  which  had  fallen  more  than 
three  degrees  when  I  saw  him.  There  were  no  positive  signs 
of  fracture  of  the  base.^ 

The  problem  immediately  presented  to  me  was,  What  is 
the  patient's  outlook  in  case  no  operation  is  done,  and  is  an 
operation  indicated?  The  x-ray  gave  us  no  evidence  of  a 
fracture  of  the  skull;  the  vault  of  the  cranium  was  intact  to 
palpation.  If  a  fracture  were  present  it  was  probably  in  the 
posterior  fossa.  Aspiration  of  the  spinal  canal,  in  the  lumbar 
region,  brought  away  a  clear  cerebro-spinal  fluid. 

I  summed  up  the  case  that  night,  therefore,  as  follows :  The 
patient  had  survived  his  injury  twenty-four  hours;  he  had 
regained  partial  consciousness  during  that  period;  evidence 
of  intracranial  pressure  was  less  than  immediately  after  the 
accident ;  there  was  no  evidence  of  cortical  damage ;  there  was 
no  positive  evidence  of  fracture  of  the  base;  there  was  no 
evidence  of  infection,  as  shown  by  the  falling  temperature. 
On  these  grounds  I  felt  justified  in  making  a  diagnosis  of 
severe  concussion,  without  laceration,^  and  with  slight  and 
diminishing  intracranial  pressure.  I  advised  delay.  The  wis- 
dom of  this  proceeding  was  demonstrated  by  the  subsequent 
history  of  the  case. 

^  In  cases  of  prolonged  unconsciousness  following  head 
injuries  one  looks  for  evidence  of  intracranial  pressure.  The 
evidence  of  such  pressure  is  twofold,  general  and  local.  The 
general  evidence  is  due  to  interference  with  the  functions 
of  the  great  centers  at  the  base  of  the  brain,  and  is  summed 
up  in  the  trilogy:  headache,  vomiting  and  blindness  (or 
choked  disk).  These  symptoms  may  or  may  not  be  asso- 
ciated with  stupor  or  coma.  The  common  stertorous  breath- 
ing is  due  to  compression  of  the  respiratory  center,  while  the 
flushed  face  and  dilated  vessels  are  due  to  irritation  of  the  vaso- 
motor center.     In  addition  to  these  general  symptoms,  one 


THE   HEAD.  8/ 

looks  for  some  special  localized  compression  or  irritation,,  such 
as  might  be  due  to  damage  of  the  motor  area  in  the  cortex, 
or  to  compression  and  injury  of  the  efferent  nerve  connections. 

2  The  outward  evidence  of  fracture  of  the  base  in  the  anterior 
fossa  —  bleeding  from  the  mouth  and  nose,  —  or  in  the 
middle  fossa  —  bleeding  from  the  ears,  —  is  obvious  and  in- 
stant, but  evidence  of  fracture  of  the  posterior  fossa  is  latent. 
The  posterior  fossa  lies  entirely  behind  the  petrous  bone,  and 
blood  from  this  fossa  finds  its  way  with  great  difficulty  to  the 
surface,  usually  appearing  after  thirty-six  hours  or  more,  as 
ecchymotic  discolorations,  in  the  region  of  the  mastoid  pro- 
cesses. 

^  Laceration  of  the  brain  may  exist  without  obvious  symp- 
toms, especially  laceration  of  some  silent  area.  Every  surgeon 
is  familiar  with  such  conditions.  In  a  previous  writing  I 
reported  the  case  of  a  man  who  remained  in  the  Massachusetts 
Hospital  for  two  weeks  after  what  appeared  to  be  a  serious 
head  injury,  and  apparently  recovered.  Just  before  leaving 
the  hospital,  however,  he  became  unsteady  in  his  gait,  took  to 
his  bed,  and  in  a  couple  of  days  died,  with  a  rapidly  rising 
temperature.  At  autopsy  nearly  half  of  the  right  parietal 
lobe  was  found  to  be  completely  disorganized.  For  such  rea- 
sons as  this  we  have  learned  to  look  upon  all  head  injuries  as 
doubtful  in  their  outcome  for  many  weeks,  and  to  enjoin  rest 
and  quiet  until  all  probability  of  latent  damage  has  been 
eliminated.  One  bears  in  mind  always,  however,  the  possi- 
bility of  Jacksonian  epilepsy  long  subsequent  to  the  injury. 
The  possibility  of  such  epilepsy  leads  us  often  to  explore  the 
brain,  even  though  the  immediate  symptoms  do  not  seem  to 
warrant  such  exploration.  In  the  case  under  consideration, 
however,  there  were  no  localizing  symptoms  and  there  was  no 
evidence  to  point  to  a  special  seat  of  injury,  so  that  any  opera- 
tion would  have  been  blind  and  haphazard. 

In  the  course  of  two  weeks  Mr.  Fox  had  completely  recovered 
his  health  and  returned  to  Philadelphia.  I  have  heard  from 
him  occasionally  since  then,  and  am  able  to  report  that  he 
never  had  any  serious  after-results,  and  continues  to-day  in 
an  active  and  successful  business  career. 


88  SURGICAL    PROBLEMS. 

Case  28.  Some  five  years  ago  I  was  summoned,  late  one 
evening,  by  a  colleague  to  see  his  mother,  seventy- two  years 
of  age,  living  in  a  neighboring  country  town.  She  was  suffer- 
ing from  a  serious  head  injury.  It  was  stated  that  about  two 
hours  before  I  saw  her  she  had  fallen  from  the  top  to  the  bot- 
tom of  a  sharp  flight  of  cellar  stairs,  striking  head  first  upon 
a  concrete  floor.  She  was  picked  up  dazed,  but  not  uncon- 
scious, and  such  was  her  condition  when  I  first  saw  her. 

This  lady  appeared  to  be  a  vigorous,  well-nourished  woman, 
who  moved  her  arms  and  legs  normally;  with  small  pupils, 
both  of  which  reacted  normally;  with  a  small  scalp  wound 
and  a  hematoma  the  size  of  a  butter  plate  over  the  right  tem- 
poral region.  There  was  a  slow,  constant  hemorrhage  from 
the  right  ear  and  right  nostril.  I  could  detect  no  fracture  of 
the  vault ;  there  were  no  paralyses ;  all  her  reflexes  were  normal ; 
she  was  said  to  have  vomited  blood ;  incidentally,  there  was  a 
comminuted  fracture  of  the  right  clavicle,  at  its  middle  third. 

Here  was  a  case  extremely  grave  in  its  outlook,  but  obvious 
in  its  nature.  There  was  certainly  a  fracture  of  the  middle, 
and  probably  of  the  anterior,  fossa.  There  was  presumably 
an  extension  of  the  fracture  into  the  vault  on  the  right  side, 
though  such  an  extension  could  not  be  made  out  by  palpation. 
A  subsequent  careful  examination  of  the  tympanum  confirmed 
this  preliminary  diagnosis.  In  this  case  our  problem  was  not 
one  of  diagnosis,  but  of  treatment.  Had  the  patient  been  a 
young  person,  and  had  the  evidences  of  intracranial  pressure 
been  more  pronounced,  I  should  have  opened  the  skull  low 
down  and  established  free  drainage,  to  minimize  and  relieve 
the  intracranial  pressure.  This  lady's  age,  however,  the  fact 
that  she  suffered  from  endocarditis,  and  the  fact  that  there 
were  no  signs  of  increasing  intracranial  pressure,  led  me  to 
temporize;  indeed,  I  do  not  think  that  in  any  case  I  should 
have  advised  operation  upon  this  patient. 

We  disinfected  carefully  the  whole  head  and  both  ears; 
encouraged  drainage  from  the  affected  ear  by  light  wicking  and 
frequent  gentle  douching,  and  wrapped  the  head  in  an  abun- 
dant absorbent  dressing.  Greatly  to  my  satisfaction,  the 
patient  made  an  uninterrupted  recovery,  —  in  my  experience 
a  rare  fact,  following  so  serious  an  injury,  especially  in  an  old 


THE   HEAD.  89 

person.  The  temperature,  which  reached  I0i°  immediately 
after  the  injury,  came  down  to  normal  on  the  second  day 
and  remained  normal ;  the  pulse  never  rose  above  80.  The  day 
after  the  accident  there  was  an  appearance  of  bloody,  dis- 
organized brain  matter  in  the  depths  of  the  right  external 
meatus,  but  there  was  never  any  further  oozing  of  brain  tissue. 
At  the  end  of  three  weeks,  save  for  occasional  slight  headaches, 
the  patient  appeared  perfectly  well,  and  remained  thereafter 
free  from  cerebral  symptoms  during  the  few  years  that  were 
left  to  her. 

The  accuracy  of  the  diagnosis  and  the  justice  of  the  treat- 
ment were  demonstrated  some  three  years  later,  when  the 
patient  died  of  pneumonia.  An  examination  of  the  head  was 
then  procured,  and  the  pathologist  demonstrated  clearly 
just  such  a  fracture  of  the  base  and  vault  as  we  had  diagnosti- 
cated at  the  time  of  the  injury.  A  considerable  callus  had 
formed  in  the  petrous  bone,  which,  incidentally,  had  caused 
an  almost  total  loss  of  hearing  on  that  side,  and  the  crack 
from  the  base  was  found  to  extend  well  up  towards  the  top  of 
the  calvarium. 


90  SURGICAL    PROBLEMS. 

Case  29.  On  the  second  day  of  September,  1907,  Jeremiah 
McCarthy  was  working  as  a  brick-layer  on  the  fourth  story 
of  a  new  building.  The  scaffolding  on  which  he  stood  gave 
way  and  he  fell  to  the  ground.  His  companion,  who  fell  with 
him,  was  killed  instantly.  McCarthy  was  carried  to  a  hospital 
where  he  remained  unconscious  for  fifty-six  hours,  according 
to  his  own  statement.  The  diagnosis  of  concussion  appears 
on  the  hospital  books.  At  the  end  of  fifty-six  hours  the  patient 
recovered  consciousness,  and  gradually  regained  comparative 
vigor.  He  did  not  recover  his  health  completely,  however. 
His  disposition  seemed  to  have  been  changed.  Previously 
a  vigorous,  rather  active-minded,  intelligent  man,  of  small 
education,  he  became  moody,  dispirited,  moping,  given  much 
to  fear  for  his  future,  the  victim  of  constant  right-sided  head- 
aches ;  he  suffered  from  loss  of  appetite  and  from  emaciation ; 
his  left  arm  was  feeble  and  he  walked  with  a  left-sided  limp. 
Such  was  his  condition  when  he  consulted  me  on  the  3d  of 
December,  three  months  after  the  accident. 

My  examination  demonstrated  little  of  positive  value. 
There  was  the  scar  of  a  slight  cut  in  the  right  parietal  region, 
but  no  evidence  of  a  fracture ;  his  hand  grasp  on  the  left  was 
feeble,  as  compared  with  the  right ;  his  left  leg  and  arm  were 
more  emaciated  than  the  right,  and  the  left  reflexes  were  nega- 
tive ;  there  was  nothing  peculiar  in  the  eyes  or  in  the  tongue, 
except  that  it  twitched  rapidly  when  extended. 

The  man  sat  in  my  offfce  in  a  depressed  attitude,  his  chin 
on  his  chest,  answered  questions  briefly  and  ineffectively, 
and  relied  apparently  entirely  on  the  active-spirited  wife,  who 
accompanied  him,  to  tell  his  story.  I  saw  him  three  or  four 
times  during  the  subsequent  six  weeks.  About  the  loth  of 
December  he  had  a  slight  left-sided  Jacksonian  convulsion, 
so  reported,  and  another  about  the  20th.  There  was  no 
further  evidence  of  a  positive  brain  lesion.  Such  evidence  as 
we  had,  however, —  the  mental  depression,  the  Jacksonian 
attacks  and  the  enfeebled  left  side, —  seemed  to  justify  us 
in  concluding  that  the  man  was  suffering  from  some  lesion 
of  the  right  motor  cortex.  Accordingly,  I  determined  to 
explore  the  right  side  of  the  brain. 

On   the    19th   of   December  I    exposed  widely  the   right 


THE   HEAD.  9I 

cortex.  I  found  no  evidence  of  damage  to  the  bone,  but 
there  was  found,  on  laying  back  the  dura,  extensive  thicken- 
ing of  the  pia-arachnoid  over  an  area  as  large  as  two  silver 
dollars.  Beneath  the  thickened  pia  we  found  those  familiar 
collections  of  fluid  which  have  acquired  the  name  meningeal 
cysts,  apparently  however  being  no  more  than  fluid  retained 
in  the  meshes  of  the  pia.  I  opened  and  evacuated  these  collec- 
tions at  several  points,  replaced  the  dura  and  removed  the 
bone  flap,  in  order  to  supply  a  permanent  decompression  to 
the  laboring  brain. 

The  man's  subsequent  history  was  interesting.  For  two 
days  after  the  operation  he  suffered  from  intense  headache 
on  the  right  side,  and  there  developed  a  marked  spasticity 
of  the  left  arm.  One  week  after  the  operation,  however,  his 
mental  condition  was  markedly  improved  and  his  paralyses 
greatly  better.  The  mental  condition,  especially,  attracted 
my  attention.  On  the  27th  of  December,  eight  days  after 
the  operation,  I  allowed  him  for  the  first  time  to  discuss 
his  experiences  with  me,  and  then  learned  much  that  was 
novel,  briefly  as  follows:  It  had  appeared  from  his  wife's 
story  that  he  remembered  nothing  of  his  accident  in  the  house 
at  which  he  was  working.  He  did  not  even  remember  what 
house  it  was,  nor  the  nature  of  his  work;  he  had  had  no  recol- 
lection of  going  to  his  work,  or  of  his  fall.  His  mind  was  a 
blank  from  the  day  before  his  accident  until  he  recovered 
consciousness  at  the  hospital,  five  days  after  the  accident. 
This  recovery  of  consciousness  was  associated,  as  I  have  stated, 
with  marked  impairment  of  mental  activity.  Compare  that 
state  of  mind  with  his  mental  condition  when  I  talked  with 
him  eight  days  after  the  operation.  He  then  welcomed  me 
most  cordially,  putting  out  his  right  hand,  and  asking  me  to 
listen  to  his  story.  He  gave  me  a  lucid  account  of  going  to 
work  on  the  morning  of  his  injury,  of  mounting  the  scaffolding, 
of  finding  some  of  the  planks  loose  and  insecure,  of  complain- 
ing of  the  danger  of  the  position,  and  warning  his  companion. 
He  even  remembered  the  giving  way  of  the  scaffolding.  After 
that,  of  course,  his  memory  was  a  blank  until  the  recovery 
of  consciousness  at  the  hospital  to  which  he  was  at  first  taken. 
All  these  things  he  recollected  perfectly  after  the  operation. 


92  SURGICAL    PROBLEMS. 

For  some  three  weeks  thereafter  his  mental  and  physical 
condition  continued  to  improve.  He  was  almost  too  joyous, 
and  looked  forward  with  complacent  certainty  to  the  recovery 
of  his  health.  After  three  weeks  he  was  up  and  about  the  ward, 
walking  with  little  difficulty,  eating  with  a  vigorous  appetite 
and  rapidly  gaining  health  and  strength.  He  left  the  hospital 
at  the  end  of  four  weeks.  From  this  date,  and  greatly  to 
my  regret,  the  entire  picture  and  scene  changed.  I  was  unable 
to  follow  his  subsequent  career  closely,  as  often  happens 
in  the  case  of  poor  patients  who  drift  away  from  hospital 
care.  It  appears,  however,  that  the  conditions  of  his  home 
life  were  unsuited  to  his  unstable  equilibrium.  Shortly  after 
going  home,  although  he  retained  perfectly  his  memory, 
he  lapsed  back  into  the  moody  and  despondent  condition  in 
which  I  first  saw  him.  He  became  physically  and  mentally 
useless,  brooding  constantly  on  his  injuries  and  on  the  pros- 
pect of  permanent  invalidism.  Such  has  continued  to  be  his 
condition.  He  is  now  an  inmate  of  a  city  institution,  with 
a  hopeless  outlook,  apparently. 

The  case  is  most  puzzling  and  unsatisfactory.  I  cannot  but 
believe  that  his  final  discharge  from  the  hospital  was  premature 
and  I  still  feel  that  under  proper  psychic  influences,  cheerful 
surroundings  and  gentle  encouragement  he  might  in  time  have 
regained  a  degree  of  health  which  should  have  enabled  him 
to  return  to  some  manner  of  useful  work.  Whether  this  is  mere 
speculation  or  not,  the  striking  feature  of  the  case  was  the 
recovery  of  a  memory  completely  lost  for  several  days,  and  the 
abolishment  of  paralyses  and  an  epilepsy  which  had  appeared 
permanent. 


THE   HEAD.  93 

Case  30.  The  following  case  is  somewhat  interesting  not 
only  for  the  extremely  grave  pathological  problem  which  it 
presents  but  for  its  medico-legal  aspects  and  as  demonstrating 
the  perverted  judgment  of  an  Interested  litigant. 

On  the  15th  of  December,  1909,  I  was  summoned  hastily 
by  a  physician  In  a  town  some  twenty  miles  from  Boston  to 
see  him  immediately  In  consultation  on  the  case  of  James  H. 
Marcy.  I  made  all  possible  haste,  and  reached  the  house 
of  the  patient  in  about  an  hour  and  a  half.  There  I  found  the 
attending  physician,  a  man  of  experience  and  excellent  judg- 
ment, together  with  the  patient's  father  and  brother.  Both 
of  these  members  of  the  family  were  Intelligent  about  the 
situation  and  most  anxious  that  everything  should  be  done 
to  save  the  patient. 

James  H.  Marcy  was  a  young  man  of  thirty.  In  comfortable 
pecuniary  circumstances,  employed  by  his  father  In  Boston 
in  a  considerable  manufacturing  business,  and  living  in  the 
country,  where  he  assisted  also  in  the  conduct  of  a  large  farm. 
Two  days  before  I  saw  him  he  was  said  to  have  fallen  from  a 
loft  in  the  farm  barn,  striking  his  head  against  a  stanchion. 
He  became  unconscious  immediately  and  had  been  unconscious 
ever  since.  For  the  first  two  days  he  was  "  treated  symptom- 
atically."  The  physician  who  called  me  saw  him  for  the  first 
time  about  three  hours  only  before  I  did. 

As  regards  further  aspects  of  the  story,  I  could  learn  merely 
that  since  the  Injury  Mr.  Marcy  had  been  continually  restless, 
rolling  his  head  about  and  throwing  out  his  arms  and  legs 
in  frequent  activity.  His  pulse  was  said  to  have  been  about  80, 
his  respirations  20  and  his  temperature  normal. 

I  found  Mr.  Marcy  to  be  a  small,  well-developed,  active- 
looking  young  man,  lying  unconscious  In  his  bed,  frequently 
groaning  and  tossing,  and  throwing  off  the  bed  clothes.  He 
dribbled  urine  and  feces.  Both  pupils  were  small  and  equally 
contracted,  though  they  reacted  very  slightly.  His  knee- 
jerks  were  active ;  there  was  no  BablnskI ;  there  were  no  cremas- 
teric or  abdominal  reflexes;  he  swallowed  imperfectly;  his 
face  was  flushed.  The  only  external  evidence  of  Injury  to  the 
head  was  a  torn  wound  of  the  right  ear.  His  pulse  was  no, 
his  temperature  by  rectum  103°,  his  respirations  20,  but  not 


94  SURGICAL    PROBLEMS. 

stertorous.  There  was  an  extensive  ecchymosis  over  the  right 
shoulder  and  a  fracture  of  the  middle  third  of  the  right  clavicle. 
I  could  not  learn  that  he  had  vomited.  He  seemed  to  be  in 
pain. 

In  view  of  the  continued  unconsciousness,  the  flushed  face, 
the  abolishment  of  reflexes,  the  contraction  of  the  pupils, 
the  bounding  character  of  the  pulse  and  the  rising  temperature, 
we  seemed  justified  in  making  a  diagnosis  of  acute,  prolonged, 
intracranical  pressure,  due  presumably  to  hemorrhage,  asso- 
ciated with  a  fracture  of  the  skull,  most  probably  at  the  base. 
Further,  in  view  of  the  time  which  had  elapsed  since  the  injury 
and  the  obvious  steady  failing  of  the  patient,  the  prognosis 
was  excessively  grave.  A  let-alone  treatment  had  availed 
nothing.  Was  it  possible  to  improve  the  conditions  or  to 
save  the  man  by  any  operation?  That  was  our  problem, 
which  I  discussed  frankly  with  Mr.  Marcy's  father.  The  elder 
man  was  most  solicitous.  I  explained  to  him  the  certainly 
fatal  outlook  as  things  were,  and  informed  him  that  the  pros- 
pect of  recovery  was  improbable.  I  suggested,  however,  that 
possibly  an  operation  for  decompression  and  drainage  might 
be  tried,  as  a  last  resort,  though  I  held  out  little  or  no  hope 
of  permanent  benefit  from  such  an  operation.  The  father 
grasped  at  this  feeble  straw,  and  urged  me  to  proceed  at  once 
with  the  suggested  trephining.  As  the  conditions  at  the 
patient's  house  were  not  favorable  for  operating,  and  as  he 
was  a  long  distance  in  time  from  my  office,  I  proposed  taking 
him  to  a  hospital  in  Boston.  This  the  father  agreed  to,  and 
had  him  promptly  transported  by  ambulance  to  a  suitable 
hospital  in  my  neighborhood. 

Late  on  that  same  day  I  operated.  The  patient's  condition 
had  changed  little,  if  any,  though  his  pulse  had  risen  to  120 
and  his  temperature  to  104°.  I  exposed  the  cranium  exten- 
sively over  the  right  hemisphere.  In  the  temporal  region  I 
found  a  long  crack  in  the  temporal  bone,  running  from  the 
vertex  down  behind  the  ear  and  widening  towards  the  base. 
Evidently  it  continued  well  into  the  posterior  fossa,  though 
I  did  not  trace  it  to  its  end.  I  removed  for  decompression 
an  area  of  bone  about  as  large  as  a  good-sized  butter  plate. 
The  dura  bulged  into  the  wound  and  did  not  pulsate.     On 


THE   HEAD.  95 

Opening  the  dura  a  large  amount  of  blood  and  clots  were 
discharged,  and  more  were  washed  away  by  gentle  irrigation. 
This  relief  of  pressure  was  followed  by  returning  pulsation 
in  the  brain.  The  pia  was  found  deeply  injected;  evidently 
an  extensive  meningitis  was  already  established.  At  this 
point  the  patient's  condition  became  very  bad.  I  hastily 
closed  the  wound  and  put  the  man  back  to  bed,  with  his  pulse 
180,  fluctuating  between  that  and  i6o.  During  the  next  six 
hours  he  improved  slightly;  his  tossings  became  much  less 
and  the  indications  of  pain  subsided;  but  his  temperature 
continued  to  rise,  and  ten  hours  after  the  operation  he  died, 
with  a  temperature  of  io8°. 

The  subsequent  developments  in  this  case  were  not  un- 
interesting. The  father  of  the  patient  disclosed  an  interesting 
mental  attitude;  he  recognized  his  obligation  to  his  son's 
memory  so  far  as  to  settle  the  accounts  for  the  ambulance 
and  for  the  hospital,  as  well  as  numerous  other  outstanding 
debts  of  his  son,  but  he  refused  absolutely  to  recognize 
the  claim  of  the  surgeon  for  the  operation,  his  statement 
being  that  the  operation  had  done  no  good,  that  his  son 
was  of  age,  not  dependent  upon  him,  that  he  himself  was  in 
no  way  responsible  for  the  medical  care  of  his  son  in  his 
last  illness,  and  that  charges  for  such  care  must  be  collected 
from  his  son's  estate.  His  son  left  no  estate,  as  the  father 
admitted.  The  situation  was  exasperating,  but  is  not  un- 
familiar to  physicians. 


THE  KIDNEY. 

Case  31.  The  winter  of  1907-8  was  punctuated  for  me  by 
an  unusual  number  of  cases  of  genito-urinary  disease,  some 
of  them  puzzling,  many  of  them  yielding  slowly  to  treatment. 

On  the  7th  of  December,  1907,  there  was  brought  to 
my  office  late  one  afternoon  a  young  woman  who  entered 
supported  on  the  arms  of  her  friends  and  in  an  apparently 
fainting  condition.  Though  married  she  appeared  as  a  girl. 
After  resting  and  being  given  stimulants  she  told  the  following 
story  with  the  help  of  her  mother  and  husband :  She  came  of 
good  stock,  and  had  always  been  well  and  vigorous  up  to  the 
time  of  her  marriage;  she  was  twenty-one,  and  two  years 
married ;  her  marriage  was  followed  by  a  miscarriage  at  four 
months,  after  which  she  was  curetted;  then  there  followed 
a  prolonged  and  obstinate  cystitis  and  urethritis,  the  latter 
of  which  persisted  when  I  saw  her.  The  previous  year, 
however,  had  not  been  one  altogether  of  invalidism ;  she  had 
been  up  and  about  mostly,  and  regarded  herself  as  perfectly 
well  during  the  first  half  of  November,  but  on  the  i8th  of 
that  month  she  was  exposed  to  cold  in  a  rough  automobile 
ride;  her  symptoms  then  returned,  and  she  took  to  her  bed, 
with  fever  and  general  abdominal  pain.  Her  physician  kept 
her  quiet  for  the  three  weeks  previous  to  her  visit  to  me, 
during  which  time,  in  addition  to  the  general  abdominal 
pain  and  frequency  of  micturition,  she  grew  gradually 
extremely  weak  and  debilitated. 

I  made  an  examination  of  her  urine  at  once,  with  this  result: 
high,  turbid,  acid  reaction,  specific  gravity  1009;  a  slight  trace 
of  albumen,  no  sugar,  and  a  large  sediment  made  up  of  coarse 
granular  casts  adherent,  much  pus  free  and  in  clumps,  renal 
cells  and  pelvic  epithelium ;  no  blood ;  a  few  squamous  cells. ^ 

On  examining  the  patient  I  found  her  to  be  a  well-developed 
but  emaciated  girl,  pallid  and  sick  looking  but  sprightly  and 
cheerful.     Her  temperature  was  102°,  her  pulse  124,  with  a 

97 


98  SURGICAL    PROBLEMS. 

leukocyte  count  of  25,000.  The  vaginal  outlet  was  not  pecu- 
liar, except  for  tenderness  about  the  meatus;  there  was  also 
some  ill-defined  tenderness  in  the  region  of  the  right  ureter. 
Higher  in  the  abdomen,  and  to  the  right  of  the  navel,  in  a 
position  corresponding  to  the  right  kidney,  was  a  tumor  the 
size  of  a  child's  head,  hard  to  the  touch,  irregular,  not  movable, 
not  tender.^ 

In  the  present  case  it  seemed  reasonable  to  conclude  that 
the  patient  was  suffering  from  a  general  septic  process  involv- 
ing finally  the  right  kidney.  The  left  kidney  and  ureter  were 
presumably  intact,  for  there  were  no  symptoms  pointing  to 
their  involvement,  while  the  total  amount  of  urine  secreted 
was  satisfactory. 

I  sent  this  patient  to  the  hospital  at  once,  and  while  giving 
an  extremely  grave  prognosis,  observed  her  condition  carefully 
for  three  days.  During  that  time  she  began  to  look  better, 
but  her  high  temperature  continued,  ranging  between  101° 
and  103°;  the  leukocyte  count  also  continued  high,  in  the 
neighborhood  of  25,000.  She  passed  twenty-four  ounces  of 
urine  in  twenty-four  hours.  It  was  soon  obvious  that  no  bene- 
fit would  result  from  palliative  measures,  and  that  delay  could 
end  only  in  her  death  in  a  few  days.  Accordingly,  after  three 
days, I  operated,  cutting  down  upon  the  right  kidney  through 
a  lateral  incision  outside  of  the  peritoneum.  I  found  the  kidney 
to  be  a  mass  about  twice  the  size  of  two  closed  fists,  and  sur- 
rounded by  extensive  dense  adhesions,  while  the  ureter  through- 
out its  length  was  greatly  thickened  and  adherent.  As  the 
patient's  condition  was  fair,  I  performed  a  rapid  nephrectomy, 
though  with  some  difiiculty,  removing  the  kidney  and  practi- 
cally the  whole  ureter.  As  often  happens  in  these  cases,  the 
renal  vessels  were  found  to  be  impaired  by  the  inflammatory 
process;  their  walls  were  thickened,  their  lumina  small,  and 
the  amount  of  blood  supplied  to  the  kidney  inconsiderable. 
I  closed  the  wound,  with  drainage,  and  was  gratified  the  next 
day  to  find  the  patient  distinctly  better. 

From  that  time  on  her  progress  to  recovery  was  uninter- 
rupted. At  the  end  of  three  weeks  she  was  sitting  up,  and 
at  the  end  of  four  weeks  she  was  taken  home,  in  a  comfortable 
condition.    Six  months  later  she  reported  to  me  as  perfectly 


THE    KIDNEY.  99 

well,  the  cystitis  and  urethritis  having  disappeared  entirely, 
and  that  without  treatment  beyond  the  use  of  urotropin.-^ 

^  The  history  and  examination,  so  far  as  obtained,  suggest 
a  postpartum  infection,  aggravated  probably  by  the  curetting. 
Evidently  this  infection  had  not  at  first  involved  the  tubes. 
There  was  the  further  question,  however,  of  a  possible  gonor- 
rhea, suggested  by  the  urethritis  and  the  cystitis;  moreover, 
the  urinalysis  pointed  clearly  to  a  pyonephrosis.  No  gonococci 
were  found. 

^  The  presence  of  a  urethritis  and  cystitis  and  tenderness 
in  the  region  of  the  right  ureter  point  strongly  to  an  ascending 
urinary  infection.  This  is  confirmed  by  the  presence  of  a 
tumor  in  the  region  of  the  kidney,  and  the  nature  of  that  tumor 
may  be  a  cause  of  some  speculation.  One  thinks  especially 
of  an  enlarged  "  surgical  kidney,"  a  kidney  the  seat  of  abscess, 
and  the  possibility  of  complicating  renal  calculi,  though  the 
history  does  not  suggest  the  presence  of  stones.  We  realize 
that  a  pus  kidney  or  **  surgical  kidney,"  so  called,  arises 
from  two  common  sources,  from  an  ascending  infection  through 
the  urethra,  bladder  and  ureter,  or  from  a  septic  infarct  of  the 
kidney  through  the  blood  stream.  The  ascending  infections 
are  often  of  slow  progress,  and  their  nature  is  indicated  by  the 
history  of  the  case;  on  the  other  hand,  an  acute  septic  hema- 
togenous infarct  arises  suddenly,  is  often  overwhelming, 
and  through  the  rapidity  of  the  process  may  lead  to  a  condi- 
tion of  extreme  danger,  and  shortly  to  death  even. 

^  The  outcome  of  this  case  was  unusually  good.  We  are 
accustomed  to  see  long-continued  suppuration  follow  the 
removal  of  these  septic  kidneys,  suppuration  promoted  es- 
pecially by  the  irritating  presence  of  an  infected  ureter, 
which  it  is  often  impossible  to  remove  entire,  so  that  I  rarely 
look  for  complete  recovery  until  at  least  a  year  has  elapsed. 
Doubtless  the  patient's  youth  was  an  important  factor  in  her 
rapid  convalescence. 


lOO  SURGICAL    PROBLEMS. 

Case  32.  Mrs.  Grass  was  said  to  be  a  purely  neurasthenic 
invalid.  Her  sister,  whose  confidence  I  seem  to  have  retained, 
sent  her  to  me  on  the  30th  of  January,  1909.  Mrs.  Grass 
was  twenty-nine  years  old,  and  had  been  married  six  years. 
She  had  one  child,  two  years  old.  She  told  me  that  she  had 
never  been  well,  although  never  acutely  ill.  She  had  suffered 
during  her  girlhood  from  fainting  "  spells  "  and  obstinate 
chronic  constipation.  Her  parents  thought  her  dehcate, 
and  consented  reluctantly  to  her  marriage.  That  event, 
however,  passed  off  without  special  turmoil,  and  her  health 
remained  about  the  same  as  formerly  until  three  years  before 
I  saw  her.  Then  she  became  acutely  ill,  and  laid  her  illness 
to  "  inhaling  turpentine."  Since  then  she  had  had  an  increase 
of  her  old  symptoms,  added  to  which  was  a  constant  burning 
under  the  right  shoulder  blade,  which  caused  "  dropping  of 
blood  into  the  liver  and  abscess  of  the  liver."  She  found  it 
difficult  to  lie  on  the  right  side.  Coincident  with  this  illness, 
her  bowels  became  more  nearly  regular,  but  she  was  troubled 
with  occasional  headaches  and  cold  sweats.  Her  appetite 
was  good.    In  the  past  three  years  she  had  lost  twenty  pounds. 

These  statements  were  supplemented  by  a  letter  from  her 
physician,  in  which  he  said  that  in  September,  1908,  "  a  liver 
and  intestinal  complication  came  on,  with  headaches,  sweating, 
chills  and  vomiting,  accompanied  by  diarrhea,  which  yielded 
to  intestinal  antiseptics.  The  backache  continues  more  and 
more  and  the  urine  shows  a  greater  increase  of  albumen, 
casts  and  pus." 

When  I  examined  Mrs.  Grass  I  found  her  a  "  neurotic  " 
looking,  smiling,  flabby  woman,  slight  and  undersized,  weigh- 
ing one  hundred  and  ten  pounds.  There  was  nothing  peculiar 
about  her  chest,  but  the  abdominal  wall  was  lax  and  the  ab- 
dominal contents  easily  palpated;  the  right  kidney  was  on  a 
level  with  the  iliac  crest,  while  the  shape  of  the  abdomen 
and  the  patient's  round-shouldered  attitude,  combined  with 
the  low-lying  abdominal  tympany,  made  practically  certain 
a  general  abdominal  visceral  ptosis.  The  urine  was  that  of 
chronic  pyelitis.^ 

At  the  time  of  my  first  interview  with  Mrs.  Grass  it  seemed 
best  that  we  should  undertake  no  operation  whatever,  but 


THE    KIDNEY.  lOI 

should  plan  a  long  course  of  proper  exercises  to  strengthen 
the  abdominal  muscles,  the  wearing  of  belts  and  braces  to 
improve  the  posture  and  to  hold  up  the  viscera,  and  the  em- 
ployment of  a  proper  diet.  Accordingly,  I  put  her  into  the 
hands  of  a  competent  physical  trainer,  had  her  wear  a  well 
fitting  corset-belt,  and  directed  her  physician  regarding  her 
diet. 

My  next  note  was  made  on  the  12th  of  March,  six  weeks 
later,  when  I  saw  the  patient  for  the  second  time.  She  was 
not  much  better.  She  complained  of  a  new  pain  near  the  end 
of  the  sternum  and  on  the  right,  and  there  appeared  to  be  a 
distinct  palpable  knuckle  at  the  spine  of  the  ninth  dorsal 
vertebra.  At  this  time  I  had  a  cystoscopic  examination  made 
and  also  catheterlzed  the  ureters.  This  examination  showed 
a  decided  pyelitis.    An  x-ray  showed  nothing  definite. 

For  the  next  seven  months  Mrs.  Grass  made  little  progress. 
Her  pain  and  discomfort  grew  no  worse,  however,  while  the 
condition  of  the  urine  was  practically  unchanged.  In  view 
of  these  facts,  supplemented  by  my  observation  that  It  was 
Impossible  properly  to  replace  the  prolapsed  and  Infected 
kidney,  I  decided  to  explore  that  organ.  At  that  time,  on 
October  5,  I  made  the  following  note:  "  The  patient  Is 
still  much  troubled  with  abdominal  distress  and  a  sense  of 
aching  and  dragging  in  the  lower  part  of  the  abdomen.  There 
is  in  the  urine  no  evidence  of  tuberculosis,  either  by  the  ordi- 
nary tests  or  by  a  guinea-pig  inoculation.  The  patient  Is  anx- 
ious for  an  operation."  ^ 

^  In  view  of  this  patient's  lifelong  Invalidism,  with  symptoms 
suggesting  an  Impaired  digestion,  with  flatulence,  distress 
after  food,  and  constipation,  alternating  with  diarrhea,  and 
in  view  further  of  the  position  of  her  abdominal  organs, 
it  seems  proper  to  assume  at  once  that  her  troubles  are  due, 
primarily,  to  a  congenital  ptosis  of  the  viscera,  and  to  recall 
the  fact  that  some  degree  of  visceral  ptosis  is  found  in  a  very 
large  proportion  of  persons,  especially  of  women. 

^  Ordinarily  In  such  a  complicated  case  as  this  the  surgeon 
is  somewhat  at  a  loss  as  to  what  operation  to  do.  The  usual 
nephropexy  accomplishes  little,  for  nephropexy  has  no  bearing 
on  the  general  ptosis.  My  decision  to  operate  was  arrived  at 
through  consideration  of  the  diseased  condition  of  the  kidney. 


102  SURGICAL    PROBLEMS. 

On  October  ii  I  cut  down  upon  the  kidney  through  a 
right  lateral  incision.  I  found  it  irregular  in  outline  and  con- 
taining several  softened  areas  beneath  the  fibrous  capsule; 
the  pelvis  and  ureter  were  greatly  thickened.  Accordingly, 
I  removed  the  kidney,  with  the  ureter;  at  the  same  time  I 
opened  the  peritoneum  and  removed  the  normal  appendix. 
The  pathologist's  report  on  the  kidney  states  that  there  ex- 
isted an  extensive  chronic  pyonephrosis. 

Mrs.  Grass  made  a  good  recovery,  and  went  home  at  the 
end  of  seventeen  days.  Her  subsequent  story  was  typical, 
and,  although  not  entirely  encouraging,  illustrates  the  slow 
improvement  which  may  follow  such  an  operation.  Three 
months  after  the  operation  she  said  that  she  had  occasional 
pain  and  distress  in  the  region  of  the  left  (remaining)  kidney 
(not  uncommon),  but  that  otherwise  she  was  improvingrapidly. 
Ten  months  after  the  operation,  however,  she  was  feeling 
greatly  better  and  seemed  to  be  more  comfortable  than  for 
years.  Of  course  the  ptosis  persisted,  but  this  was  fairly  well 
corrected  by  the  wearing  of  a  comfortable  abdominal  support. 


THE   KIDNEY.  IO3 

Case  33.  Late  one  evening  In  May,  1910,  I  was  called  hast- 
ily by  a  physician  in  the  neighboring  town  of  Braybrook  to  see 
a  patient  who  was  acutely  ill.  I  arrived  at  the  house  about 
midnight,  and  heard  the  following  story.  The  patient,  Mrs. 
Smiley,  was  sixty-two  years  old  and  the  mother  of  several 
children.  She  had  reached  the  age  of  fifty-seven  without  any 
special  ill-health.  In  the  past  five  years,  however,  she  had  had 
a  great  deal  of  "  dyspepsia  "  and  two  severe  and  distinct  at- 
tacks of  pain  in  the  left  loin,  at  which  time  she  passed  a  little 
blood  from  the  bladder.  The  pain  at  these  times  lasted  one 
or  two  days  and  was  excruciating  In  character.  The  last  at- 
tack occurred  six  months  before  I  saw  her.  Three  days  before 
my  visit  she  had  a  third  attack.  In  which  she  was  seen  by  my 
consultant.  He  described  her  as  writhing  on  the  floor  and 
screaming  in  agony.  He  said  the  pain  was  In  the  left  loin 
and  coursed  down  towards  the  bladder,  following  the  line 
of  the  left  ureter.  This  pain  was  lessening  somewhat,  but 
was  still  severe.^ 

I  found  Mrs.  Smiley  to  be  a  robust,  active-looking  woman, 
lying  in  bed  In  a  tense  attitude,  flushed  and  anxious  In  appear- 
ance. Her  temperature  was  104°,  her  pulse  120,  her  respira- 
tions 30  and  shallow ;  her  skin  hot  and  dry.  The  nurse  stated 
that  she  had  passed  but  six  ounces  of  urine  In  the  previous 
twenty-four  hours.  She  had  a  slight  endocarditis;  while 
I  was  examining  her  she  vomited;  there  was  no  edema  any- 
where ;  her  abdomen  w^as  not  distended ;  there  was  an  extremely 
tender  area  In  the  left  costovertebral  angle,  so  tender  that 
I  could  not  palpate  satisfactorily  or  make  out  a  mass.  The 
one  urgent  fact  about  her  condition  was  that  she  was  appar- 
ently dying  of  uremia,  and  unless  the  kidneys  could  be  stimu- 
lated to  proper  functionating  no  operation  was  to  be  consid- 
ered for  a  moment.^ 

I  agreed  with  my  consultant  that  his  fears  for  Mrs.  Smiley 
were  entirely  justified,  and  explained  to  the  patient's  family 
the  extremely  grave  nature  of  her  Illness.  Before  doing  any- 
thing further,  I  attempted  to  stimulate  the  right  kidney  to 
further  action,  and  much  to  my  satisfaction  and  somewhat  to 
my  surprise  I  accomplished  this  in  the  next  twelve  hours, 
through  the  use  of  the  hot-air  bath  and  nitroglycerine.     By 


104  SURGICAL   PROBLEMS. 

noon  of  the  following  day  the  patient  was  reported  to  be  in 
comparative  comfort,  to  be  sweating  copiously  and  to  be  pass- 
ing frequently  urine  in  two  and  three-ounce  amounts.  She  was 
then  removed  to  a  hospital,  where  I  found  her,  eighteen  hours 
after  my  first  interview  with  her,  lying  comfortably  in  bed, 
with  her  temperature  99°,  her  pulse  84,  and  her  condition 
greatly  improved,  while  she  was  passing  a  good  amount  of 
urine.  For  the  next  three  days  her  general  symptoms  im- 
proved steadily,  but  her  condition  still  remained  one  of  ex- 
treme gravity.  A  careful  series  of  x-rays  showed  no  calculus. 
Cystoscopic  examinations,  however,  informed  us  that  the  left 
kidney  was  secreting  practically  no  urine,  but  the  indigo- 
carmine  test  demonstrated  a  right  kidney  functionating  well. 
Accordingly,  I  advised  an  operation  upon  the  left  kidney. 

I  undertook  this  operation  with  a  good  deal  of  hesitancy,  but 
I  felt  that  it  was  imperative,  if  we  were  to  forestall  another 
attack,  which  might  end  fatally.  I  employed  nitrous  oxide 
and  oxygen  anesthesia, —  a  great  advantage  when  one  is  deal- 
ing with  impaired  kidneys,  as  it  has  little  or  no  general  de- 
pressing effect  and  has  no  effect  whatever  on  the  kidney 
parenchyma.  I  exposed  with  some  difficulty  the  left  kidney, 
through  a  wide  incision  In  the  flank.  The  kidney  was  found 
slightly  enlarged,  studded  with  five  or  six  areas  of  softening, 
suggesting  abscesses,  and  a  number  of  small  injected  areas, 
evidently  infarcts.  On  opening  the  pelvis  and  passing  my 
finger  Into  the  callces  I  could  discover  no  stones,  but  the  kidney 
tissue  was  extremely  friable,  tearing  and  bleeding  profusely 
with  the  slightest  handling.  From  the  renal  pelvis  there  es- 
caped about  one  ounce  of  pus.  The  ureter  was  not  abnormal. 
In  view  of  the  extensive  hemorrhagic  condition  of  the  kidney 
and  its  great  friability,  and  In  view  of  the  difficulty  of  con- 
trolling hemorrhage,  I  decided  against  the  minor  operation  of 
drainage.  Accordingly,  I  removed  the  whole  kidney,  with  the 
ureter,  a  somewhat  difficult  operation  under  the  circumstances 
but  the  only  possible  procedure,  I  believe,  as  I  now  review  the 
case. 

The  patient  rallied,  with  little  pain,  and  entered  well  upon 
her  convalescence.  Unfortunately,  her  condition  was  so  de- 
pressed that  it  seemed  unlikely  she  could  withstand  any  of  the 


THE    KIDNEY.  IO5 

storms  incident  to  recovery  from  such  an  operation.  I  said 
that  we  evacuated  an  abscess  in  the  renal  pelvis.  From  this 
pus  an  infection  occurred.  Mrs.  Smiley  grew  acutely  ill  on 
the  fourth  day,  her  left  chest  became  quickly  involved  in  a 
pneumonic  process,  and  she  died  just  one  week  after  the  oper- 
ation.^ 

^  The  history  of  the  case  up  to  this  point  suggests  most 
strongly  a  renal  or  ureteral  calculus,  and  this  was  the  view 
of  the  case  which  I  took  until  I  saw  the  patient. 

^  The  sudden  onset  of  the  pain,  its  excruciating  character, 
the  suppression  of  urine  and  the  characteristic  tenderness 
in  the  costo-vertebral  angle  point  emphatically  to  an  acute 
renal  infection  of  hematogenous  origin.  Evidently  this  patient 
had  passed  through  two  somewhat  similar  crises,  the  nature 
of  which  had  gone  unrecognized.  These  acute  infections 
(acute  hemorrhagic  infarcts  of  the  kidney)  are  overwhelming 
and  often  promptly  fatal.  Wide  areas  of  the  kidney  are  quickly 
destroyed,  suppression  of  urine  supervenes  and  the  patient 
dies,  apparently  of  acute  septicemia.  We  have  learned  that 
the  one  imperative  method  of  treatment  in  the  extreme  cases  is 
promptly  to  remove  the  kidney,  if  we  can  assure  ourselves 
that  the  kidney  of  the  opposite  side  is  properly  doing  its 
business. 

^  All  surgeons  who  are  experienced  in  this  grave  disease 
and  in  the  high  mortality  which  follows  acute  hemorrhagic 
infarcts  of  the  kidney  will  recognize  the  dangerous  condi- 
tion of  Mrs.  Smiley  from  the  start.  Indeed,  it  would  not 
have  been  surprising  had  she  died  in  one  of  her  earlier  attacks 
of  infection.  The  unfortunate  outcome  of  the  case  while 
in  my  hands  goes  merely  to  confirm  me  in  my  judgment 
that  early,  prompt  and  radical  measures  are  necessary  if 
these  patients  are  to  be  saved. 


EMPYEMA. 

Case  34.  Miss  Fanny  Johnson  was  an  unfortunate  woman, 
at  the  end.  When  I  first  saw  her  in  March,  1910,  she  was  fifty- 
three  years  old.  She  had  been  a  school-teacher  all  her  life, 
and  a  successful  school-teacher, —  active,  energetic,  physically 
and  mentally  competent,  never  neurotic,  rarely  ill.  On  the 
25th  of  February,  1910,  she  had  a  sharp  attack  of  pneumonia, 
and  from  that  time  the  important  points  in  her  story  are 
summed  up  for  me  by  her  attending  physician  in  the  following 
scanty  words:  "  Two  weeks  ago  she  had  pneumonia;  after 
a  week  the  temperature  fell;  we  thought  she  was  getting  well, 
but  slowly;  four  days  ago  we  tapped  her  right  chest  and  drew 
off  about  twelve  ounces  of  thin  pus.  She  is  very  sick.  What 
shall  we  do?  "  ^ 

This  is  a  rather  characteristic  story,  and  I  do  not  know  that 
the  physicians  in  the  case  conducted  it  improperly.  It  would 
be  a  rather  tough  narrative,  however,  to  put  before  a  jury  or 
an  audience  of  critical  medical  students.  One  asks,  "  What 
were  you  doing  during  the  week  before  the  tapping?  What 
was  the  patient's  condition?  Was  she  very  ill?  Had  you  no 
reason  to  suspect  pleurisy  or  empyema?  Did  you  realize  the 
frequency  of  this  complication  after  pneumonia?  "  Surgical 
consultants  are  often  regarded  as  having  an  easy  time  of  it, 
because  a  definite  diagnosis  has  become  clear  late  in  the  illness 
before  they  are  called  in.  This  is  often  true,  but  the  ease 
of  the  diagnosis  is  offset  frequently  by  the  hopelessness 
of  the  condition  which  they  are  asked  to  treat,  and  by  the 
blame  they  get  if  the  patient  dies  after  a  desperate  operation. 

When  I  saw  Miss  Johnson  I  extracted  from  her,  haltingly 
and  feebly,  the  following  story.  Since  the  subsidence  of  her 
pneumonia  she  had  grown  increasingly  weak,  without  appetite, 
with  pain  in  the  right  chest,  with  frequent  nausea,  with  a  sense 
of  great  prostration  and  illness ;  she  thought  now  that  she  was 
probably  dying;  at  no  time  in  the  past  two  weeks  had  she  been 
in  any  way  comfortable. 

107 


I08  SURGICAL    PROBLEMS. 

The  temperature  by  chart  was  seen  to  range  during  the 
past  week  from  ioo°  to  103°,  working  slowly  upwards;  the 
pulse  from  90  to  no  ;  the  respirations  from  24  to  40,  The 
patient  was  so  weak  and  the  diagnosis  so  certain  after  the  tap- 
ping that  I  made  no  delay  with  auscultation  and  percussion.^ 

A  quickly  performed  drainage  operation  through  the  chest 
wall  produces  little  shock  and  is  extremely  effective.  I  decided 
on  such  an  operation  in  Miss  Johnson's  case,  in  spite  of  the 
fact  that  she  was  badly  septic  and  that  her  chances  of  recovery 
were  slight;  moreover,  her  heart  was  acting  badly  and  there 
was  an  obvious  endocarditis ;  but  to  have  left  her  would  have 
meant  certain  death  within  a  few  hours.  Accordingly,  I 
gave  her  a  little  ether,  enough  to  stimulate,  and  without 
moving  her  from  the  bed  I  opened  the  chest  quickly  in  the  back 
beneath  the  ninth  rib,  without  excising  the  rib,  and  inserted 
a  rubber  spool,  which  established  complete  and  efficient 
drainage.  In  a  few  minutes  the  patient  had  recovered  from 
the  anesthetic,  and  assured  us  that  she  felt  greatly  relieved 
already.  Unfortunately,  the  toxemia  was  too  deep  for  cure 
by  the  simple  treatment  of  drainage.  After  a  few  hours  of 
comfort,  Miss  Johnson  sank  rapidly  and  died  during  the  suc- 
ceeding night,  her  pulse  ranging  rapidly  upward  and  her  tem- 
perature reaching  105°. 

Although  this  case  may  strike  the  reader  as  belonging 
properly  to  the  internist,  and  to  be  of  little  interest  in  this 
place,  I  protest  that  it  teaches  an  important  and  serious  lesson, 
—  the  imperative  necessity  which  rests  with  the  family 
physician  to  investigate  thoroughly,  and  with  consultation 
if  need  be,  a  chest  which  does  not  clear  up  after  the  crisis  of 
pneumonia,  and  the  urgent  need  of  emptying  such  a  chest 
should  it  become  the  seat  of  empyema. 

1  The  character  of  the  pus  withdrawn  was  interesting ;  it 
was  thin,  greenish,  sweet  and,  I  was  told,  loaded  with  pneu- 
mococci.     The  tapping  gave  the  patient  some  slight  relief. 

2  There  is  often  little  excuse  for  failing  to  make  a  diag- 
nosis of  pleuritis  with  effusion,  except  when  the  effusion  is 
small  and  pocketed.  A  chest  full  of  fluid  should  never  be 
mistaken  for  a  consolidated  lung,  because  the  exploring 
needle  always  settles  the  question. 


EMPYEMA.  109 

Case  35.  John  Vanderbilt  was  nineteen  years  old  when  I 
saw  him  in  the  accident  room  of  the  Massachusetts  General 
Hospital,  on  the  25th  of  June,  1910.  He  was  a  carpenter,  born 
in  Nova  Scotia,  and  had  always  been  well  and  vigorous.  It 
was  noted  of  him  especially  that  he  had  had  no  previous  bowel 
disturbance,  or  digestive  troubles,  or  urinary  disorders. 
His  present  symptoms  began  four  days  before  I  saw  him, 
when  he  was  seized  with  severe  general  abdominal  pain, 
without  nausea  or  vomiting  or  chills.  After  three  days  he 
went  to  bed,  so  severe  was  the  pain.  He  had  chilly  sensations 
then,  and  some  nausea.  His  bowels  were  loose  throughout 
these  days,  and  he  had  three  or  four  watery  movements 
daily,  without  blood  or  mucus.  For  the  two  days  before  enter- 
ing the  hospital  he  had  a  slight  cough,  with  some  thick,  green 
expectoration.  Such  was  his  story  when  I  saw  him  in  the 
hospital. 

The  boy  looked  haggard  and  anxious.  His  belly  was  dis- 
tended, firm,  tense,  tympanitic  everywhere;  it  was  especially 
tender  beneath  the  right  rectus,  in  the  neighborhood  of  the 
navel,  and  there  was  spasm  of  the  rectus.  Examination  by 
rectum  caused  high,  intense  pain.  His  temperature  was  105.2°, 
pulse  no  and  respirations  24.  The  case  seemed  to  me  a  clear 
one  of  diffuse  peritonitis,  arising  probably  from  an  appendi- 
citis or  a  diverticulitis.  I  operated  immediately.  I  found 
a  normal  appendix  and  removed  it.  There  was  nothing  peculiar 
within  the  abdomen  except  distention  of  the  intestines. 
There  was  no  peritonitis.  I  explored  the  cavity  as  well  as 
I  could  with  the  patient  in  an  almost  dying  condition,  but 
found  nothing  to  account  for  his  symptoms.  The  abdomen 
was  then  closed  and  drained  with  a  small  wick. 

Within  twenty-four  hours  the  temperature  had  dropped 
to  normal,  the  pulse  to  80  and  the  respirations  to  20,  but  the 
patient  did  not  recover;  he  lost  ground  steadily.  Ten  days 
after  the  operation  his  fever  returned  and  ranged  between 
normal  and  104°.  Nothing  positive  could  be  made  out  of  his 
blood;  we  could  not  make  a  diagnosis  of  typhoid  fever;  the 
leukocyte  count  ran  from  10,000  to  20,000.  My  colleagues 
at  the  hospital  In  consultation  could  not  help  us.  On  the 
14th   of  July,    Dr.  J.  J.   Minot   made   a   physical   examina- 


no  SURGICAL    PROBLEMS. 

tion,  which  was  absolutely  negative,  except  for  the  abdominal 
wound.  On  the  17th  of  July,  twenty- three  days  after  the 
operation,  the  patient  had  a  sudden  chill,  with  pain  in  the 
right  lower  chest;  there  was  no  cough,  dyspnea  or  cyanosis. 
The  pain  recurred  at  intervals  for  a  few  days.  On  the 
1 8th  the  heart  was  found  displaced  to  the  left  and  some 
fluid  was  discovered  in  the  right  chest.  The  next  morning 
Dr.  Minot  withdrew  300  ccm.  of  cloudy  serum  from  the  right 
side.    The  fluid  contained  an  atypical  streptococcus. 

I  then  took  over  the  patient,  and  the  next  day  operated, 
removing  a  portion  of  the  eighth  rib  and  clearing  out  one  and 
one-half  pints  of  thin  greenish  pus.  That  was  on  the  20th 
of  July,  1910.  The  patient  remained  in  the  hospital  for  many 
weeks,  the  cavity  slowly  closing  until  at  the  time  of  my  last 
report,  in  December,  he  asserted  that  he  felt  well  and  expected 
soon  to  go  to  work  again. ^ 

^  The  obvious  lesson  in  this  case  lies  in  the  occasional  extreme 
difficulty  of  diagnosis  of  abdominal  and  thoracic  diseases. 

Long  ago  we  learned  that  the  early  symptoms  of  pneu- 
monia may  simulate  the  early  symptoms  of  appendici- 
tis, but  as  Moynihan  has  said,  with  pneumonia  in  mind  and 
after  a  careful  physical  examination  a  correct  diagnosis  should 
be  reached.  In  the  case  of  Mr.  Vanderbilt,  however,  repeated 
physical  examinations,  by  various  competent  attendants, 
failed  to  discover  anything  wrong  in  the  chest,  while  the  state 
of  the  abdomen  on  the  patient's  entrance  to  the  hospital 
was  almost  typical  of  a  fulminating  peritonitis,  with  source 
in  the  right  inguinal  region.  Observe  that  the  rather  active 
diarrhea  from  which  the  patient  suffered  does  not  necessarily 
contra-indicate  a  peritonitis.  The  second  point  in  this  case, 
as  contrasted  with  Case  34,  is  the  prompt  discovery  and  treat- 
ment of  his  pleuritis.  Doubtless  this  young  man  would  have 
become  septic  and  died  within  a  few  days  had  not  his  chest 
been  relieved  by  operation. 


INTESTINAL. 

Case  36.  It  occasionally  happens  that  even  the  most 
experienced  surgeon  is  forced  to  wonder  why  patients  suffer 
the  extreme  of  misery  before  applying  for  assistance.  Mrs. 
Byrd  had  suffered  for  thirty-one  years.  When  she  consulted 
me  on  the  ist  of  July,  1910,  she  was  fifty-four  years  old. 
Her  trouble  began  with  her  one  and  only  confinement,  at  the 
age  of  twenty-three.  Her  active  and  solicitous  son,  the  cause 
of  all  the  trouble,  brought  her  to  me.  Briefly,  it  appeared 
that  with  that  child-birth  there  occurred  a  bad  tear  of  the  peri- 
neum into  the  rectum,  which  later  was  twice  repaired.  There 
had  always  persisted  a  recto-vaginal  fistula,  so  that  part  of  the 
fecal  stream  passed  by  the  vagina.  This  miserable  and  de- 
pressing condition  had  persisted  without  change,  and  yet 
the  woman  lived  on,  a  respected  member  of  the  community. 
She  went  through  the  menopause  at  forty-eight.  Her  general 
health  until  within  six  months  had  been  fair,  though  with  a  poor 
digestion  and  chronic  constipation.  Various  endeavors  had 
been  made  to  close  the  recto-vaginal  fistula.  At  one  time  it 
looked  as  though  a  successful  closure  had  been  accomplished 
through  some  form  of  flap-splitting  operation.  Unfortunately, 
however,  this  operation  resulted  only  in  causing  a  great  amount 
of  scar  tissue  to  form  about  the  rectum,  with  a  resulting  serious 
stricture,  above  which  the  fistula  remained  open.  From 
that  time  on  nearly  the  whole  of  the  fecal  stream  passed 
through  the  vagina,  and  the  woman's  misery  was  greatly 
increased.  For  the  six  months  previous  to  my  seeing  her  she 
had  declined  greatly.  A  chronic  proctitis  existed,  with  a  con- 
stant discharge  of  mucus  and  pus.  Of  course  there  was  an 
extreme  degree  of  vaginitis.  With  all  this  there  was  a  constant 
septic  absorption,  a  leukocyte  count  of  18,000,  a  temperature 
ranging  from  100°  to  103°,  and  a  nasty,  quick,  irregular  pulse 
running  from  90  to  100.  The  other  organs  of  her  body  w^ere 
unimpaired.^ 


112  SURGICAL    PROBLEMS. 

On  examining  Mrs.  Byrd  I  found  her  to  be  a  person  appar- 
ently a  great  deal  older  than  her  given  age.  She  was  fifty-four; 
she  appeared  seventy-four.  She  seemed  old,  haggard,  worn, 
with  poor  pulse  and  no  vitality.  In  view  of  these  facts,  I 
judged  it  unwise  to  attempt  any  of  the  exhausting  plastic 
operations  for  repair  of  the  rectum  and  vagina.  I  believe 
she  would  have  died  on  the  table.  In  order  to  bring  her 
into  some  sort  of  condition,  however,  and  to  make  her  life 
more  tolerable,  I  decided  on  a  quick  colostomy.  This  proved 
easy,  the  lower  end  of  the  sigmoid  being  brought  up  into 
a  wound  in  the  left  groin  made  by  muscle  splitting.^ 

^  The  ordinary  operations  for  closing  a  recto-vaginal  fistula 
of  this  extent  are  useless.  Such  operations  —  refreshing  the 
edges  and  bringing  them  together  —  can  succeed  only  when 
the  field  is  clean.  An  extremely  useful  operation,  however, 
and  one  too  little  employed,  is  that  which  consists  in  a  partial 
proctectomy,  or  excision  of  the  anus  and  lower  part  of  the  rec- 
tum. This  is  done  in  the  ordinary  manner,  through  the  peri- 
neum; the  encircling  incision  is  made  about  the  anus,  the  rectum 
is  dissected  loose  and  is  drawn  down  until  the  portion  contain- 
ing the  fistula  is  delivered  outside  of  the  sphincter,  the  fistula, 
of  course,  being  dissected  loose ;  the  rectum  is  cut  off  outside 
and  stitched  to  the  skin.  This  operation  is  not  particularly  dan- 
gerous and  is  extremely  effective. 

^  The  important  item  in  performing  colostomy  is  to  bring 
up  a  goodly  amount  of  slack  bowel  into  the  wound  from  below, 
so  that  there  shall  exist  above,  a  good-sized  pouch  for  the  col- 
lection of  fecal  material.  If  the  upper  part  of  the  sigmoid 
is  drawn  tightly  into  the  colostomy  wound  there  will  exist 
no  proper  pouch  above  the  wound,  so  that  there  will  be  a  con- 
stant passage  of  feces,  greatly  to  the  distress  of  the  patient. 

Within  two  days  Mrs.  Byrd  began  to  improve.  At  the  end 
of  ten  days  the  wound  had  healed  well,  and  the  fecal  stream 
was  passing  entirely  by  the  artificial  anus.  She  came  back 
to  health  slowly,  of  course,  but  I  had  the  satisfaction  of  seeing 
her  some  two  months  after  the  operation,  at  her  house  in 
the  country,  where  she  appeared  to  have  grown  younger  by 
twenty  years.  She  managed  the  artificial  anus  easily,  with 
a  well-constructed  apparatus,  which  she  changed  but  twice 
daily,  while  the  freedom  from  distress  and  the  moral  benefit 
were  striking. 


THE   BONES. 

Case  37.  William  Epsom,  seven  years  old,  was  brought 
to  see  meon  the  7th  of  July,  1910,  by  his  agitated  physician. 
Four  weeks  before  I  saw  him  the  boy  was  said  to  have  fallen 
and  broken  his  left  forearm.  His  physician  stated  to  me  that 
the  lesion  was  a  double  greenstick  fracture,  both  bones  being 
broken ;  that  he  straightened  the  bones,  with  the  patient  under 
ether,  without  trouble ;  and  he  showed  me  an  x-ray  of  the  bones 
taken  the  following  day.  This  x-ray  did  not  suggest  a  green- 
stick  fracture,  but,  rather,  a  subperiosteal  fracture  of  both 
bones.  The  position  and  alignment  were  perfect.  The  physi- 
cian stated  further  that  after  reducing  the  fracture  he  put 
up  the  forearm  in  anterior  and  posterior  splints.^ 

During  the  following  four  weeks  the  physician  saw  the  child 
several  times,  but  did  not  remove  the  splints,  as  the  "  hand 
appeared'  natural  and  limber  "  and  the  splints  appeared  to  be 
holding  the  arm  in  excellent  position. ^  The  day  before  I  saw 
the  patient  the  physician  took  off  the  splints,  expecting  to  find 
a  straight  arm,  with  union.  To  his  mortification,  he  found 
a  bent  forearm,  with  soft  union,  the  radius  being  slightly  bent 
and  the  ulna  being  bent  at  a  considerable  angle,  about  20°. 

When  I  examined  the  boy  I  found  the  condition  to  be  as 
had  been  described  to  me.  The  child  was  a  ruddy,  active  lad, 
of  excellent  heredity  and  in  sound  health.  In  addition  to  the 
deformity  of  the  forearm  already  mentioned,  I  found  large 
calluses  about  the  four  bone  ends,  rendering  the  straightening 
of  the  arm  very  difficult.  With  the  patient  under  nitrous  oxide 
anesthesia,  I  straightened  the  bones  and  put  them  up  care- 
fully in  an  internal  angular  splint  and  anterior  and  posterior 
splints.  I  then  had  another  x-ray  taken.  This  x-ray  was 
disappointing.  It  showed  that  the  great  callus  on  the  poste- 
rior aspect  of  the  ulna  rendered  proper  splinting  and  straight- 
ening of  the  bones  practically  impossible.^ 

^  Fractures  of  the  forearm  are  best  retained  in  position  by 
immobilization  either  in  plaster  of  Paris  or  in  anterior  and 

"3 


114  SURGICAL    PROBLEMS. 

posterior  splints,  supplemented  always  by  a  right-angle  splint 
fixing  the  elbow  joint.  This  fixation  of  the  elbow  joint  is 
extremely  important,  if  the  bones  of  the  forearm  are  to  be  kept 
at  rest.  Moreover,  the  splints  on  the  forearm  should  be  care- 
fully adapted  to  the  size  of  the  arm  and  should  be  well  padded. 

2  The  care  of  fractures,  especially  in  the  first  week  after 
the  accident,  is  difficult;  malposition  takes  place  easily  inside 
of  the  most  carefully  applied  splints  even ;  moreover,  muscular 
contractures  due  to  tight  strapping  may  occur  (Volkmann's 
contracture) ,  unless  the  arm  be  frequently  inspected. 

^  At  first  thought  this  impossibility  of  straightening  the 
bone  does  not  seem  likely,  but  when  one  recalls  the  fact  that 
the  ulna  is  closely  united  to  the  radius  both  at  the  elbow  and 
wrist  joints  the  mechanical  difficulties  of  the  situation  become 
apparent.  Had  I  waited  a  couple  of  months,  until  union 
was  solid  and  the  callus  had  diminished,  it  would  have  been 
much  easier  to  refracture  and  reduce  properly  the  damaged 
ulna. 

In  spite  of  every  ejffort,  frequent  dressings  and  frequent 
x-rays,  I  found  it  impossible  to  secure  a  union  of  the  ulna 
in  proper  position.  So  long  as  the  active  processes  of  bone 
formation  continued,  the  great  callus  persisted,  rendered  en- 
tirely apparent  by  the  x-ray.  I  secured  a  good  deal  of  improve- 
ment, however,  over  the  extreme  deformity  as  I  first  saw  the 
fracture,  but  eventually  the  bones  united  at  something 
of  an  angle,  the  radius  nearly  straight,  the  ulna  distinctly 
bent.  The  arm  was  strong  and  flexible,  however,  and  the 
child  in  the  course  of  three  months  was  able  to  take  part 
in  the  games  of  other  boys.  Fortunately  for  the  family 
physician  and  for  his  consultant,  the  family  of  the  child  were 
reasonable  and  recognized  the  difficulties  of  the  situation. 
My  final  advice  was  that  they  wait  for  some  months,  until 
the  callus  had  subsided,  when  it  would  be  possible,  if  thought 
best,  to  make  an  open  fracture  and  plate  the  bones  in  a  straight 
position.  Later  the  mother  of  the  boy  informed  me  she  was 
so  well  satisfied  with  the  present  condition  that  she  should 
wait  until  the  child  grew  older,  so  that  he  might  decide  for 
himself  about  any  secondary  operation. 


^ 


BONES.  115 

Case  38.  A  bright  little  girl,  six  years  of  age,  was  sent  to 
me  in  July,  1910,  by  her  physician  in  the  country,  to  have  her 
fractured  wrist  examined  and  treated,  if  necessary.  I  under- 
took the  case  at  a  disadvantage.  The  child  was  what  is 
commonly  known  as  a  "  spoiled  child."  For  more  than  half 
an  hour  in  my  office  she  threw  herself  about  on  the  floor,  kick- 
ing, screaming,  and  biting  all  who  came  within  reach.  Of 
course  it  was  necessary  to  give  her  an  anesthetic  —  nitrous 
oxide  —  but  the  excessive  activities  of  the  patient,  except 
while  she  was  under  the  anesthetic,  rendered  proper  treatment 
extremely  difficult. 

I  report  this  case  because  as  a  fracture  it  was  somewhat 
unusual.  The  left  forearm  was  broken  near  the  wrist  —  not 
a  Colles  fracture,  but,  as  the  x-ray  showed,  a  clean  fracture 
through  both  bones,  about  one  inch  above  the  wrist  joint. 
One  might  suppose  that  this  would  be  a  simple  affair  to  treat, 
but  on  considering  the  anatomy  of  the  parts  one  finds  that  the 
pronator  quadratus  muscle  binds  tightly,  as  in  a  sheath,  these 
two  bones  at  the  point  of  fracture.  The  result  is  that  the 
upper  fragments  of  both  bones  are  drawn  together  when  a 
fracture  occurs,  so  that  a  perfect  alignment  is  difficult  to  attain. 
The  x-ray  plate  showed  this  condition  beautifully.  Both  lower 
fragments  projected  slightly  outside  of  the  upper  fragments. 
At  first  I  was  inclined  to  transform  the  fracture  into  an  open 
fracture,  in  order  to  secure  perfect  alignment  by  plating, 
but  on  consideration  it  seemed  best  to  try  first  a  week  or  two 
of  careful  splinting.  The  splinting  was  successful.  An  x-ray 
taken  two  weeks  later  showed  the  alignment  to  be  nearly 
perfect,  and  at  the  end  of  a  month  union  was  firm,  without 
the  slightest  deformity,  and  the  motions  of  the  wrist  and  fin- 
gers good.^ 

^  The  circumstances  of  this  case  illustrate  again,  if  illustra- 
tion were  needed,  the  difficulties  and  annoyances  of  fracture 
practice.  Unthinking  persons,  and  laymen  especially,  assume 
that  the  reduction  and  care  of  a  fracture  is  an  easy,  straight- 
forward matter,  requiring  no  special  skill.  The  fact  is  that 
failure  to  secure  a  perfect  cosmetic  and  functional  result  is 
so  obvious  to  the  patient  and  his  friends  that  no  class  of  cases 
puts  a  surgeon  more  upon  his  mettle.    This  particular  case  — 


Il6  SURGICAL    PROBLEMS. 

the  child  being  the  daughter  of  a  well-known  and  exacting 
business  man  in  Chicago  —  caused  me  much  trouble,  and  while 
the  father  admitted  that  the  result  of  the  treatment  was  ex- 
cellent, he  persisted  in  regarding  the  whole  affair  as  trifling ; 
yet  had  the  case  turned  out  badly,  and  the  wrist  been  deformed 
ever  so  slightly,  this  man  would  undoubtedly  have  made 
trouble  for  me,  probably  by  bringing  suit  in  the  courts, —  a 
frequent  outcome  of  fracture  treatment. 


BONES.  117 

Case  39.  Wallace  Bonesteel  was  a  vigorous  lad  of  seven- 
teen. His  physician  brought  him  to  my  office  on  the  4th  of 
November,  1907,  He  was  a  senior  school-boy  in  one  of  the 
large  New  England  boarding-schools,  and  was  particularly 
active  at  football.  He  was  a  big  fellow,  weighing  one  hundred 
and  seventy  pounds,  tall,  strong  and  well  developed.  His 
previous  health  had  been  excellent;  there  was  no  story  of 
typhoid,  scarlatina  or  arthritis.  One  month  before  I  saw  him 
he  was  severely  bruised  in  a  football  scrimmage,  being  struck 
on  the  front  of  the  right  thigh.  There  followed  considerable 
pain  and  stiffness  for  many  days,  but  the  lad  continued  playing 
football.  Two  weeks  later  he  was  struck  again  In  the  same 
spot.  This  second  injury  was  followed  by  a  marked  swelling 
of  the  thigh,  and  for  the  next  two  weeks  he  was  kept  in  bed, 
with  the  leg  bandaged.    Then  he  was  brought  to  see  me. 

I  found  him  free  from  pain,  and  looking  well,  but  the  leg 
was  weak  and  the  thigh  swollen.  On  inspection  I  found 
a  mass  lying  on  the  front  of  the  thigh,  and  apparently  con- 
nected with  the  rectus  muscle,  about  eight  Inches  In  length 
and  of  an  elliptical  shape,  roughly  about  the  size  and  propor- 
tions of  the  half  of  a  split  watermelon.  The  swelling  was  hard ; 
at  Its  lower  angle  there  was  a  sense  of  obscure  fluctuation. 
The  mass  seemed  to  terminate  about  four  fingers'  breadths 
above  the  patella ;  at  that  point  there  was  a  marked  depression, 
as  though  from  damage  to  the  fascia  of  the  rectus.  No  x-ray 
was   taken. ^ 

Young  Bonesteel's  physician  had  made  a  diagnosis  of 
laceration  of  the  rectus  muscle,  with  hematoma,  and  I  con- 
curred In  his  opinion.  So  extensive  was  the  swelling,  however, 
and  so  Indolent  its  progress  towards  recovery,  that  I  advised 
an  operation  to  remove  the  mass. 

Two  days  later  I  went  to  the  school  and  operated.  The 
findings  were  Interesting.  I  opened  the  great  swelling  through 
a  four-Inch  incision  on  its  outer  side,  and  dissected  down 
through  the  soft  parts  to  the  shaft  of  the  femur,  which  ap- 
peared much  enlarged.  I  found  no  superficial  hematoma, 
nor  any  damage  to  the  rectus  or  other  muscles.  Enlarging 
the  incision,  I  scraped  away  the  muscles  on  the  front  and  outer 
side  of  the  femur  for  a  short  distance,  and  discovered  that  the 


Il8  SURGICAL    PROBLEMS. 

swelling  was  of  the  femur  itself,  on  the  front  of  which  there 
had  developed  what  appeared  to  be  a  bone  cyst, —  a  smooth, 
rounded,  oblong  enlargement  of  the  bone,  evidently  containing 
fluid.  I  opened  into  this  mass,  when  immediately  there  es- 
caped twenty  ounces  of  a  sticky,  straw-colored  serum.  On 
enlarging  the  opening  in  the  cyst  still  further  and  following 
the  shaft  of  the  femur  up  and  down,  I  ascertained  that  the 
swelling  extended  from  just  above  the  patella  to  within  four 
inches  of  the  lesser  trochanter  of  the  femur;  that  is  to  say,  it 
seemed  to  involve  three  fifths,  at  least,  of  the  shaft  of  that  bone. 
The  cyst  wall  was  thick,  cartilaginous,  with  occasional  bony 
plates  developing  in  the  cartilage.  At  the  bottom  of  the  cyst 
was  the  shaft  of  the  femur,  nodular,  roughened,  irregular, 
covered  with  purple  granulations.  At  this  point  I  found  my- 
self compelled  to  desist,  because  I  had  promised  the  boy's 
parents,  by  wire,  that  I  would  do  no  serious  operation,  and 
the  look  of  things  at  this  point  certainly  was  serious.  I  did 
not  know  the  exact  nature  of  the  cyst,  nor  the  extent  of  the 
operation  which  might  be  necessary.  A  high  amputation 
seemed  uncalled  for,  yet,  if  this  tumor  should  prove  to  be 
sarcoma,  amputation  at  the  hip  joint  was  inevitable.  Ac- 
cordingly, I  removed  portions  of  the  cyst  wall  and  of  the 
deep  granulations  for  examination,  and  closed  the  wound, 
preliminary  to  a  later  and  more  extensive  operation.  The 
patient  rallied  promptly  from  his  anesthetic,  and  felt  very  well 
the  next  day. 

I  submitted  the  portions  of  the  tumor  to  Dr.  William  F. 
Whitney.  His  report  is  interesting,  for  the  condition  is  not 
by  any  means  common,  though  I  suppose  all  persons  exposed 
to  serious  injuries  may  expect  to  suffer  as  did  young  Bonesteel. 
Dr.  Whitney  writes:  "  Microscopic  examination  showed  a 
fibrous  tissue  structure,  in  which  small  scattered  areas  of  bone 
were  formed,  normal  in  appearance  except  that  the  lime  salts 
were  sparingly  deposited  in  them.  In  the  inner  part  of  the 
wall  of  the  cyst  there  was  considerable  hemorrhage.  The  inner 
surface  was  smooth  and  fibrous.  There  is  no  evidence  of 
a  sarcomatous  growth,  and  the  condition  is  consistent  with 
a  periosteal  inflammation,  which  may  have  been  caused 
by  some  injury  which  had  produced  hemorrhage  between 


BONES.  119 

the  periosteum  and  bone.     Shortly  expressed,  the  diagnosis 
is  subperiosteal  hematoma."- 

^  Severe  injuries  to  the  extensors  of  the  thigh  are  common 
in  football.  The  nature  of  the  familiar  lesion  "  poop  "  is 
usually  a  partial  or  complete  tear  of  the  sheath  of  the  rectus 
muscle;  sometimes  many  bundles  of  muscle  fibers  also  are 
damaged  or  destroyed.  There  results  hematoma,  and  weaken- 
ing of  the  leg.  The  usual  treatment  consists  of  rest,  with  the 
leg  in  an  elevated  position,  bandaging  and  cold  applications. 

^  You  will  observe  that  this  cyst  was  not  that  form  of  tumor 
commonly  known  as  "  bone  cyst."  This  cyst  was  a  sub- 
periosteal hematoma,  entirely  outside  of  the  shaft  of  the  bone. 
Ordinary  bone  cysts  develop  within  the  shaft,  and  cause  a 
distention,  thinning  and  even  destruction  of  the  shaft  itself. 

Young  Bonesteel's  parents  immediately  saw  the  need  of  a 
further  operation,  and  authorized  me  to  proceed,  which  I  did 
five  days  later.  The  rest  of  the  story  is  a  simple  one:  I 
exposed  the  shaft  of  the  femur,  turned  aside  the  soft  parts 
and  trimmed  and  chiseled  away  the  whole  of  the  cyst  wall, 
leaving  exposed  the  granulating  shaft;  I  closed  the  great 
wound  with  drainage,  and  had  the  satisfaction  ten  days 
later  to  find  it  soundly  healed.  This  lad  had  a  prolonged  and 
stormy  convalescence,  however.  After  recovering  entirely 
from  his  operation,  but  before  leaving  his  bed,  he  developed 
a  pericarditis  and  was  invalided  for  many  months.  Eventu- 
ally he  regained  his  health,  and  is  now  an  active  athlete  in  one 
of  our  large  colleges. 


HERNIA. 

Case  40.  Georgina  Mahoney  was  thirty-seven  years  old 
when  her  physician  in  the  country  asked  me  to  see  her 
with  him,  on  the  28th  of  October,  1902.  She  was  a  hard- 
working woman  in  a  country  store,  and  gave  a  long  history 
of  ill-health, —  scarlet  fever  when  ten  years  old,  followed  by 
dyspnea  and  palpitation  ten  years  later,  evidently  due  to  a 
heart  affection  which  persisted.  During  the  years  before  I  saw 
her  she  developed  a  train  of  troublesome  dyspeptic  symptoms, 
—  distaste  for  food  in  the  morning,  a  constantly  poor  appetite, 
great  flatulence,  sour  stomach  and  constipation,  five  or  six 
times  a  year  attacks  of  abdominal  pain,  located  mainly  in  the 
left  lower  quadrant  of  the  abdomen,  but  associated  also  with 
occasional  acute  epigastric  pain  and  pain  in  the  left  groin. 
During  the  previous  year  she  had  lost  about  twenty  pounds 
in  weight.  Three  days  before  I  saw  her  she  had  suffered  from 
one  of  these  attacks,  and  took  to  her  bed,  with  constant 
nausea,  general  abdominal  pain  and  a  rising  fever.  ^ 

The  patient  lay  in  bed,  languid  and  flushed,  weak  and  mod- 
erately cheerful,  her  pulse  no,  her  temperature  99°.  She  said 
that  she  had  been  more  comfortable  during  the  past  few  hours ; 
her  nausea  had  ceased  and  her  bowels  were  moving;  the  pain 
also  had  diminished  greatly.  On  examining  the  heart  I  found 
it  somewhat  enlarged,  the  apex  being  in  the  mammary  line 
and  the  right  side  distinctly  to  the  right  of  the  sternum; 
there  was  a  loud  systolic  murmur  at  the  apex,  but  compensa- 
tion seemed  to  be  good.  So  much  for  the  heart  at  present. 
On  examining  the  abdomen,  however,  I  found  a  condition 
which  was  striking;  the  belly  was  somewhat  distended  and 
tympanitic;  there  was  no  tenderness  anywhere  except  In  the 
left  groin,  tenderness  running  down  towards  the  vulva  and 
thigh ;  in  the  left  groin  was  a  mass  the  size  of  a  goose  egg,  — 
more  accurately,  It  was  a  mass  projecting  from  the  Inguinal 
ring  and  burrowing  towards  the  vulva ;  it  was  tense,  slightly 
reddened    and    tender;   it  was   slightly   fluctuant,   but   not 


122  SURGICAL    PROBLEMS. 

tympanitic,  apparently  an  inguinal  hernia  composed  of 
omentum.  On  careful  cross-questioning  I  ascertained  that 
this  mass,  of  greater  or  lesser  size,  had  persisted  for  some 
fifteen  years. ^ 

Evidently  Miss  Mahoney  had  suffered  during  the  previous 
three  days,  and  at  varying  intervals  in  the  past,  from  partial 
strangulation  of  the  omentum  in  the  hernia.  The  condition 
seemed  to  me  to  be  serious,  and  in  spite  of  the  state  of  her 
heart  I  advised  an  operation  to  remove  excess  of  omentum 
and  to  close  the  ring.  As  a  rule,  such  a  damaged  heart  as  I 
have  described  bears  well  ether  anesthesia  and  a  short  opera- 
tion, though  one  remembers  always  that  the  operation  for 
inguinal  hernia  in  enfeebled  persons  is  by  no  means  devoid 
of  danger.  Such  persons  have  low  resisting  powers,  they 
become  easily  infected,  and  in  the  face  of  infection  their 
hearts  quickly  fail.     Accordingly,  I  operated  the  next  day. 

The  operation  was  simple  and  quickly  done.  On  opening 
the  hernial  sac  I  found  a  large  piece  of  incarcerated  omentum, 
about  the  size,  when  spread  out,  of  a  woman's  pocket  hand- 
kerchief. This  omentum  was  thick  and  rather  ugly  looking; 
the  circulation  in  it  was  impaired,  while  there  were  two  or  three 
spots  which  showed  a  beginning  gangrenous  process.  I 
removed  all  the  suspicious  omentum,  enlarged  the  ring, 
returned  the  carefully  tied  omental  stump  and  did  a  radical 
cure  of  the  hernia.  The  patient  stood  the  operation  well, 
and  all  promised  favorably.^ 

The  next  day  I  found  that  Miss  Mahoney  had  failed  to 
rally  as  I  expected.  She  had  much  continuous  and  de- 
pressing nausea  all  day.  On  the  second  day,  however,  her 
bowels  moved  well,  her  abdomen  became  flat,  her  pulse 
improved,  her  temperature  fell  to  normal  and  the  outlook  was 
good.  For  a  week  we  believed  that  she  was  on  the  high- 
road to  recovery.  On  the  6th  of  November,  however,  eight 
days  after  the  operation,  my  consultant  called  me  urgently 
to  see  her.  I  found  that  she  had  been  failing  during  the  pre- 
ceding night ;  her  vomiting  had  returned,  her  heart  was  flutter- 
ing, her  pulse  was  soft  and  extremely  rapid,  ranging  from  120 
to  160,  edema  of  the  legs  had  appeared  and  the  urine  had 
diminished ;  her  temperature  fluctuated  in  the  neighborhood 


HERNIA.  123 

of  102°.  There  seemed  no  reason  to  suspect  peritonitis, 
for  there  was  no  abdominal  tenderness  and  the  bowels  were 
moving  well;  nor  was  there  distention.  She  never  rallied,  but 
sank  into  a  muttering  delirium  and  died  that  night,  evidently 
of  disease  of  the  heart.^ 

^  The  given  list  of  symptoms  suggests  two  distinct  condi- 
tions; a  cardiac  disease,  with  probable  dilatation  and  lack  of 
compensation,  and,  secondly,  some  serious  organic  derange- 
ment of  the  gastro-intestinal  tract.  The  absence  of  appetite 
in  the  morning  and  the  generally  poor  appetite  go  very  well 
with  a  visceral  ptosis;  while  the  pain  in  the  left  lower  quad- 
rant of  the  abdomen  might  mean  diverticulitis  or  some  form 
of  intestinal  stricture;  moreover,  the  pain  in  the  epigastrium 
seemed  more  suggestive  of  a  chronic  duodenal  or  gastric  ulcer, 
or  possibly  of  gallstones. 

^  An  incarcerated  inguinal  hernia  composed  of  omentum, 
and  of  long  duration,  may  or  may  not  cause  serious  trouble. 
The  chances  are,  however,  that  trouble  eventually  will  arise. 
The  firmly  attached  omentum  drags  upon  the  transverse 
colon  and  stomach,  and  causes  general  indefinite  abdominal 
pains.  Constipation  is  common,  but  the  most  important 
consideration  is  the  probability  of  strangulation.  The  open 
ring  seems  to  attract  more  and  more  omental  material.  ^  A 
sudden  stoppage  of  the  circulation  may  arise,  and  extensive 
necrosis  of  the  omentum  may  result. 

^  The  tying  off  of  an  omental  stump  is  not  always  a  simple 
matter.  Do  not  put  around  it  a  mass  ligature,  but  tie  it 
in  small  sections,  preferably  with  absorbable  catgut.  A  mass 
ligature  may  slip,  and  serious  or  fatal  hemorrhage  may  result. 

■*  This  case,  like  others  which  I  have  reported,  brings  forci- 
bly home  to  the  surgeon  the  question  of  operating  in  the 
face  of  grave  conditions  threatening  death.  One  cannot  say 
what  would  have  been  the  outcome  had  I  postponed  the  opera- 
tion, but  the  imminence  of  a  general  infection  gave  reason 
enough  for  operating  when  I  did.  On  the  other  hand,  had 
the  operation  been  postponed,  had  it  been  done  a  month 
later  even,  it  is  probable  that  the  seriously  damaged  heart 
would  in  any  case  have  failed.  We  cannot  state,  as  is  often 
lightly  stated,  that  a  bad  heart  is  not  hurt  by  ether.  Ether 
certainly  does  depress  the  resisting  powers.  In  1902  we  were 
not  using  spinal  anesthesia.  I  believe  that  that  method,  as 
used  to-day,  would  have  given  this  patient  a  far  better  oppor- 
tunity for  recovery. 


124  SURGICAL    PROBLEMS. 

Case  41.  A  physician  practicing  in  Vermont  sent  me  an 
urgent  message  on  the  1st  of  November,  1909,  stating  that 
he  was  bringing  down  to  Boston  a  patient  acutely  ill  with  some 
obscure  abdominal  disease,  and  asking  my  assistance.  The 
next  morning  he  reached  the  hospital  with  his  patient,  and 
1  saw  them  at  once.  The  story  was  as  follows :  The  patient, 
Mrs.  Booth,  was  a  married  woman  of  fifty-two,  and  enor- 
mously fat,  weighing  some  325  pounds.  She  had  borne  one 
child  twenty  years  before,  but  without  special  disturbance. 
There  was  nothing  else  notable  in  her  past  history,  except 
that  she  was  a  farmer's  wife  and  had  lived  on  an  inferior  diet 
all  her  life.  Some  twelve  years  before  I  saw  her  she  had 
begun  to  suffer  with  dragging  pains  in  the  abdomen,  indefi- 
nite in  location,  irregular  in  time,  save  that  they  usually 
came  on  late  in  the  day ;  they  appeared  to  be  made  worse  by 
eating,  the  pain  reaching  its  maximum  three  hours  after 
taking  food,  and  gradually  disappearing  without  special 
cause.  On  waking  in  the  morning  she  was  comfortable.  She 
never  noticed  any  special  point  of  pain  or  tenderness,  beyond 
observing  that  she  was  more  sore  below  the  navel  than  above 
it.  In  the  past  five  years  she  had  grown  larger  than  ever,  and 
believed  that  her  abdomen  was  now  constantly  distended. 
She  had  passed  the  menopause  some  four  years.  During  the 
past  four  years  her  distressing  symptoms  had  increased,  and 
now  included  morning  headache  and  nausea,  extremely  ob- 
stinate constipation,  increased  flatulence  and  decidedly  in- 
creased pain.  Her  physician  informed  me  that  there  was  no 
doubt  latterly  about  the  rapid  growth  of  her  abdomen;  that 
she  appeared  as  a  person  bearing  a  large  ovarian  tumor; 
that  the  whole  lower  part  of  the  abdomen  was  flat.  He  had 
observed  this  condition  for  some  months.  At  the  time  of  his 
telegraphing  to  me  he  was  especially  disturbed  because 
the  patient  had  that  day  experienced  a  sudden  access  of  low 
abdominal  pain,  with  a  quickening  of  the  pulse  to  loo,  and  one 
degree  of  fever,  together  with  great  prostration.  He  felt 
that  she  was  suffering  probably  from  a  twisted  ovarian  cyst.^ 

I  found  Mrs.  Booth  to  be  an  extremely  difficult  patient  to 
examine,  on  account  of  her  great  size.  Her  heart  and  lungs 
were  sound,  the  tongue  clean  and  the  urine  normal,  and  she 


HERNIA.  125 

seemed  as  a  vigorous,  hard-working  woman,  of  cheerful  tem- 
perament. The  abdominal  wall  was  extremely  fat.  A  pelvic 
examination  was  almost  impossible,  on  account  of  the  diffi- 
culty of  making  satisfactory  bimanual  palpation.  I  could 
discover  nothing  that  seemed  like  an  ovarian  cyst ;  if  there  were 
one,  it  was  probably  high  and  beyond  reach.  The  uterus  was 
in  good  position,  small  and  movable.  The  abdomen  was 
nowhere  particularly  tender,  though  there  was  somewhat 
more  tenderness  in  the  region  of  the  navel  than  elsewhere. 
On  palpating  carefully  the  adipose  abdomen  I  was  able  to 
make  out,  at  the  bottom  of  the  umbilical  pit,  a  distinct  en- 
largement of  the  umbilical  ring,  and  below  that  a  mass  which 
seemed  to  be  an  unusual  accumulation  of  encapsulated  fat. 
This  mass  protruded  on  the  patient's  coughing,  while  at  the 
same  time  the  umbilical  ring  filled  up  with  extruded  viscera. 
On  percussion  the  whole  lower  portion  of  the  abdomen  was 
dull,  in  places  almost  to  flatness. 

All  these  findings  were  most  unsatisfactory.  I  was  utterly 
unable  to  form  an  exact  opinion  of  the  patient's  exact  condi- 
tion, the  only  positive  abnormality  being  a  fairly  well 
marked  hernia  at  and  below  the  navel.  In  view  of  these  facts, 
and  considering  the  long-continued  illness,  with  its  sharp 
turn  for  the  worse,  it  seemed  to  me  best  to  do  an  exploratory 
operation. 

I  operated  the  next  day,  accordingly,  giving  the  patient  the 
benefit  of  nitrous  oxide  and  oxygen  anesthesia.  I  opened  down 
upon  the  umbilical  ring  and  the  hernia  mass  through  a  long 
incision,  when  on  dissecting  back  the  parietal  fat  I  disclosed 
a  clearly  marked  hernia,  protruding  partly  through  the  um- 
bilical ring  and  partly  through  a  great  split  in  the  sheath  of  the 
rectus  below  It.  The  hernial  sac  contained  a  mass  of  omentum 
nearly  as  large  as  two  fists  flattened  out,  everywhere  adherent 
and  dragging  constantly  upon  the  abdominal  contents.  I 
removed  most  of  the  omentum,  carefully  tying  the  pedicle 
in  sections,  opened  the  abdomen  further,  returned  the  omental 
stump  and  explored  the  abdomen.  I  found  nothing  peculiar 
within  the  cavity ;  all  the  viscera  were  well  placed  and  normal 
to  the  touch.  Accordingly,  I  performed  a  satisfactory  opera- 
tion for  radical  cure  of  the  hernia.    The  patient  made  a  prompt 


126  SURGICAL    PROBLEMS. 

convalescence  and  returned  home  at  the  end  of  three  weeks, 
perfectly  well.    She  has  remained  well  ever  since. ^ 

^  The  train  of  symptoms  described  is  indefinite  and  suggests 
a  number  of  disturbances.  The  physician's  assumption  that 
there  was  an  ovarian  cyst  present  was  entirely  reasonable, 
in  view  of  the  history.  These  cysts,  as  is  well  known,  are 
often  associated  with  marked  digestive  disorders  such  as  the 
patient  described.  One  thinks  of  abdominal  ptosis  also, 
though  abdominal  ptosis  with  marked  dyspeptic  symptoms 
is  uncommon  in  very  fat  persons.  There  was  nothing  es- 
pecial to  suggest  gallstones,  peptic  ulcer,  or  appendicitis. 
Looking  at  the  case  broadly,  it  seemed  to  be  one  of  some 
digestive  disorder,  secondary  to  a  probable  pelvic  disturb- 
ance. 

^  This  form  of  hernia  is  unusual  and  is  somewhat  difficult 
to  deal  with.  The  ring  cannot  be  closed  in  the  way  that  one 
ordinarily  closes  an  umbilical  ring;  that  is  to  say,  by  over- 
lapping the  aponeurosis  through  a  transverse  incision.  I 
was  obliged  to  overlap  from  side  to  side;  but  the  resulting 
union  was  sound  and  satisfactory. 

The  symptoms  of  omental  hernise,  whether  of  the  umbilical 
variety  or  elsewhere  in  the  abdomen,  are  often  puzzling  and 
most  troublesome.  When  incarcerated  these  herniae  cause  a 
constant  dragging  upon  the  viscera,  and  if  they  do  not  lead 
to  a  condition  of  partial  ptosis,  cause  symptoms  strongly 
suggestive  of  ptosis,—  the  symptoms  especially  of  some 
obscure  digestive  disorder. 


HERNIA.  127 

Case  42.  Mrs.  Dixson,  a  Russian  Jewess  of  forty-one, 
sixteen  years  resident  in  this  country,  consulted  me  on  the 
I2th  of  August,  1910.  Her  physician  stated  that,  in  addi- 
tion to  her  physical  disablements,  she  was  a  hopeless  neuras- 
thenic. She  had  experienced  six  pregnancies  in  the  ten  years 
previous  to  my  seeing  her.  A  hard-working  woman  always, 
of  fairly  good  heredity,  she  could  tell  me  nothing  important 
of  her  history  before  marriage.  The  pregnancies,  however, 
were  associated  with  various  disorders,  and  she  enumerated 
the  following :  failure  of  vision,  morning  nausea  and  headache, 
daily  dyspnea,  flatulence,  a  constant  sense  of  dragging  at  the 
navel,  intolerable  low  backache,  tenderness  at  the  hepatic 
and  splenic  flexures  of  the  colon,  chronic  constipation  and 
scalding  on  urination,  with  frequent  urinary  incontinence.  In- 
cidentally, she  stated  that  in  1905  she  had  been  operated  upon 
at  one  of  our  large  hospitals  for  double  inguinal  hernia, 
but  that  both  herniae  returned  within  two  months  after  the 
operation.  She  said  that  later  she  discovered  a  small  swelling 
at  the  navel,  which  she  supposed  to  be  an  umbilical  hernia. 
These  things  would  have  troubled  her  little  had  not  some 
unwise  person  suggested  to  her  that  she  had  tipping  of  the 
womb  also.  Since  then  her  mental  distress  had  outweighed 
her  physical  miseries. 

Mrs.  Dixson  was  a  mild,  pathetic,  easily-weeping  woman, 
in  fair  flesh,  five  feet  four  inches  in  height,  worn  and  tired 
looking;  her  eyes  were  not  peculiar,  her  heart  and  lungs 
were  sound,  the  urine  was  not  abnormal.  On  examining 
her  abdomen  I  found  some  evidence  of  recurrence  of  the 
inguinal  herniae ;  a  recurrence  certainly  was  present ;  the  um- 
bilical ring  was  large  and  there  was  a  slight  protrusion  there 
when  she  coughed.  Her  perineum  was  extensively  torn  and 
there  was  a  wide  bilateral  tear  of  the  cervix;  the  uterus  was 
somewhat  larger  than  normal,  was  retrocessed  and  prolapsed. 
Here,  then,  was  a  collection  of  positive  physical  ailments,  the 
correction  of  which  the  patient  demanded.^ 

^  The  interest  in  this  case  lies  in  the  number  of  lesions 
to  be  repaired  and  the  grave  doubt  as  to  the  future  usefulness 
of  the  patient,  in  view  of  her  mental  condition.  No  one  of 
the  lesions  was  especially  serious,  yet  they  all  seemed  serious 


128  SURGICAL    PROBLEMS. 

to  Mrs.  Dixson.  Should  I  correct  two  or  three  of  them,  or 
should  I  correct  them  all?  She  knew  of  them  all,  and  would 
be  dissatisfied  with  a  partial  operation.  At  the  same  time, 
I  greatly  feared,  and  justly,  that  no  amount  of  operating  would 
return  her  to  sound  mental  health.  The  problem  was  one  such 
as  must  always  test  severely  a  surgeon's  judgment  and  patience. 
Had  this  woman  been  in  a  different  social  or  financial  position, 
or  had  she  been  the  victim  of  long-continued  and  futile  medi- 
cal treatment,  I  should  have  refused  to  operate  at  all.  As 
it  was,  in  consideration  of  her  confiding  temperament,  her 
hopefulness,  her  insistence,  and  the  positive  need  of  an  ana- 
tomical cure,  in  order  that  she  might  work  for  her  living,  I 
decided  on  doing  all  the  operations  indicated. 

Having  decided  on  operating,  therefore,  I  gave  Mrs.  Dixson 
the  benefit  of  a  long  rest  in  bed,  careful  feeding  up,  and  regula- 
tion of  the  bowels.  I  had  her  anesthetized  with  nitrous 
oxide  and  oxygen,  and  found  her  in  excellent  condition  on  the 
morning  of  the  operation.  I  operated  as  follows:  i.  By 
dilatation  and  curettage  of  the  uterus.  2.  By  elaborate  re- 
pair of  the  perineum.  3.  By  repair  of  a  small  incarcerated 
omental  hernia  at  the  umbilicus.  4-5.  By  secondary  repair 
of  the  two  recurrent  inguinal  hemise.  6.  By  suspension  of 
the  uterus.  This  was  a  long  job,  but  the  patient  stood  it  well, 
and  fifteen  minutes  after  the  end  of  the  operation  was  conscious 
and  in  excellent  spirits. 

This  case  I  have  reported  because  it  is  a  problem  in  what 
to  do.  The  number  of  individual  operations  did  not  seem  to 
affect  materially  the  usual  course  of  convalescence.  The 
wounds  healed  promptly  and  satisfactorily.  Within  four  weeks 
Mrs.  Dixson  went  home,  and  has  reported  to  me  frequently 
ever  since.  She  was  not  strong  and  vigorous  when  I  last  saw 
her,  six  months  after  the  operation,  but  she  was  much  better 
than  before  the  operation,  suffered  little  from  any  positive 
symptoms,  and  looked  forward  with  confidence  and  equa- 
nimity to  returning  to  hard  work  within  a  few  weeks. 


THE   LIVER  AND  DUCTS. 

Case  43.  An  unusually  interesting  problem  in  abdominal 
disease  was  that  of  Mrs.  Marion,  a  woman  of  thirty-seven, 
living  in  a  town  near  Boston,  to  whom  I  was  called  in  consulta- 
tion on  the  3d  of  September,  1905.  She  was  three  years 
married,  but  her  previous  history  had  been  somewhat  stormy. 
When  eighteen,  and  before  the  days  of  antitoxin,  she  suffered 
from  a  severe  diphtheria, which  was  followed  by  many  months 
of  "  nervous  breakdown  "  and  disease  of  the  nasal  passages. 
This  nasal  disease  persisted  so  that  when  I  saw  her  there 
was  present  an  active  ulceration  of  the  septum,  with  perfora- 
tion. She  had  long  been  subject  to  severe  frontal  headaches 
and  to  frequently  recurring  attacks  of  biliousness,  with  the 
usual  associated  chronic  constipation.  Seven  weeks  before 
I  saw  her  she  was  confined  at  term  of  a  macerated  fetus, —  her 
only  confinement.  Her  convalescence  was  slow;  after  four 
weeks  she  was  curetted  for  a  septic  infection  of  the  uterus, 
with  a  temperature  rising  to  l02°-3°  and  incessant  nausea 
and  vomiting.  After  the  curetting  this  attack  subsided. 
Some  ten  days  later,  or  about  ten  days  before  my  visit,  she  had 
another  attack  of  nausea  and  vomiting,  lasting  six  days.  From 
this  again  she  recovered.  It  was  not  apparent  that  this  second 
attack  of  nausea  and  vomiting  was  associated  with  the  first, 
but  the  presumption  is  that  it  was  so.  Six  days  before  I  saw 
her  she  had  so  far  recovered  as  to  be  feeling  confortable  on  a 
liquid  diet.^ 

In  the  interval  between  the  two  attacks  of  nausea  and  vomit- 
ing Mrs.  Marion  was  seen  by  a  well-known  Boston  internist, 
who  was  said  to  regard  the  condition  as  one  of  intestinal 
indigestion.  Six  days  before  my  visit,  after  a  slight  increase 
in  diet,  the  patient's  nausea  and  vomiting  returned,  with 
alarming  prostration.  At  that  time  her  regular  physician  was 
away  on  his  vacation,  and  she  was  seen  by  my  immediate 
consultant.  He  reported  that  at  the  time  of  his  first  visit 
her   temperature  was  102°,   pulse  114,  and   respirations  22; 

129 


130  SURGICAL    PROBLEMS. 

that  she  was  having  two  or  three  attacks  of  vomiting  daily; 
that  she  had  "  resistance  "  in  the  right  hypochondrium ;  and 
that  there  was  a  sHght  mitral  systolic  murmur  at  the  heart 
apex.  The  urine  showed  a  trace  of  albumen ;  it  was  concen- 
trated and  there  were  a  few  hyaline  casts ;  there  had  been  no 
improvement  during  the  two  days  preceding  my  visit. 

On  examining  Mrs.  Marion,  I  found  her  to  be  a  rather  slight 
but  well-developed,  intelligent  woman,  looking  much  younger 
than  her  years.  She  was  flushed,  with  a  temperature  of  103°, 
a  dry,  coated  tongue  and  an  appearance  of  anxiety.  The  heart 
was  slightly  enlarged  and  there  was  present  a  systolic  mitral 
murmur.  The  abdomen,  however,  was  the  seat  of  special 
Interest.  I  examined  first  the  pelvis,  and  found  the  organs 
there  to  be  well  placed  and  In  excellent  condition.  The  whole 
abdomen  was  slightly  distended,  tympanitic  and  somewhat 
rigid ;  there  was  tenderness  over  the  whole  colon  and  marked 
tenderness  at  McBurney's  point;  the  right  rectus  was  held 
tense  and  there  was  spasm  throughout  its  extent;  the  liver 
dullness  was  much  increased,  descending  to  within  two 
inches  of  the  navel,  while  the  epigastric  region  and  the  region 
of  the  liver  were  intensely  sensitive  to  examination ;  there  was 
no  jaundice,  the  bowels  were  moving  fairly  well ;  there  was  a 
constant  slight  nausea,  however,  and  the  associated  distaste 
for  food.^ 

In  view  of  the  patient's  prostration,  and  her  fever,  coupled 
with  the  evidently  acute  infection  of  the  bile  passages,  it 
seemed  best  to  me  to  employ  palliative  measures  for  a  day  or 
two  longer.  The  internist  who  had  seen  Mrs.  Marion  before 
me  visited  her  again  on  the  day  of  my  visit,  and  urged  strongly 
the  unwisdom  of  operating.^  I  saw  her  again  on  the  next  day, 
when  I  found  her  condition  little  changed  —  certainly  with 
no  sign  of  improvement.  I  should  have  operated  on  that  day 
had  I  not  been  overruled  by  my  consultants.  On  the  next 
day,  however,  as  no  improvement  had  occurred,  and  the  situa- 
tion had  become  distinctly  alarming,  I  felt  that  bile  duct 
drainage  was  imperative,  if  the  patient's  life  was  to  be  saved. 
Accordingly,  I  operated,  and  quote  the  following  statement 
from  my  notes:  "  On  opening  down  upon  the  bile  passages 
I  found  slight  adhesions  about  the  gall  bladder,  though  the 


LIVER   AND   DUCTS.  I3I 

stomach  and  duodenum  were  not  involved.  The  bile  passages 
were  thickened  also,  and  were  easily  palpable.  The  left  lobe 
of  the  liver  extended  to  within  two  inches  of  the  umbilicus. 
The  appendix  was.  found  to  be  covered  with  slight  old  adhe- 
sions, the  organ  itself  five  inches  long,  kinked  at  its  middle, 
thickened  and  injected. 

1  removed  the  appendix,  which  was  catarrhal,  its  mucosa 
studded  with  minute  hemorrhages.  I  opened  the  gall  bladder 
and  passed  a  probe  readily  into  the  common  duct,  meeting 
with  no  obstruction;  no  stones  were  there;  the  gall  bladder 
was  somewhat  thickened  and  its  mucosa  deeply  injected; 
there  escaped  thin  black  bile ;  unfortunately,  no  cultures  were 
taken  from  this  discharge.  These  findings  confirmed  the  diag- 
nosis of  cholangitis.  The  liver  was  not  peculiar,  save  for  its 
considerable  increase  in  size.  I  performed  cholecystostomy, 
draining  the  gall  bladder  through  a  stab  wound.^ 

^  Mrs.  Marion's  history  since  her  confinement  is  somewhat 
confusing  up  to  this  point.  When  unraveled  it  appears  to 
contain  the  following  incidents :  ( i )  An  infection  of  the  uterus, 
for  which  she  was  curetted  three  weeks  after  confinement; 

(2)  shortly  after  that  an  attack  of  nausea   and  vomiting; 

(3)  ten  days  later  a  second  attack  of  nausea  and  vomiting. 
One  must  endeavor,  if  possible,  to  distinguish  the  attack  of 
nausea  and  vomiting  from  the  puerperal  condition,  although 
the  latter  may  have  had  to  do  with  the  development  of  the 
former.  Nausea  and  vomiting,  of  course,  are  not  uncommon 
during  the  puerperium,  and  are  usually  associated  with  an 
infection.  On  the  other  hand,  the  fact  that  Mrs.  Marion 
had  long  been  subject  to  "  bilious  attacks  "  may  be  regarded 
as  a  primary  factor  in  her  recent  disorders.  One  must  consider 
further  the  bearing  of  the  old  diphtheria  on  the  situation. 
Had  it  not  been  for  the  history  of  a  definite  diphtheria,  one 
would  suppose  that  her  perforated  septum  and  her  bearing 
of  a  macerated  fetus  were  indications  of  a  syphilis.  A  careful 
study  of  the  case,  however,  eliminated  that  possibility. 

2  The  conditions  I  have  described  enabled  us  with  fair 
assurance  to  rule  out  a  number  of  suggested  disorders;  the 
enlargement  of  the  liver,  especially,  being  significant.  Gastric 
disease  was  improbable,  as  the  vomiting  had  not  been  charac- 
teristic of  either  ulcer  or  gastritis;  there  was  no  excess  of  hy- 
drochloric acid  in  the  A^omitus;  the  symptoms  were  not  severe 
enough   to  suggest  acute  pancreatitis;  the  kidney  was  not 


132  SURGICAL    PROBLEMS. 

palpable,  and  the  urine  did  not  indicate  a  severe  disease  of 
that  organ,  certainly  not  a  suppurative  process.  There  re- 
mained, therefore,  as  the  two  most  probable  conditions, 
a  sub-acute  appendicitis  and  some  derangement  of  the  liver 
and  bile  passages.  We  talk  about  perihepatitis  and  general 
diffuse  inflammation  of  the  liver;  these  conditions  are  com- 
monly associated  with  infections  starting  either  in  the  appendix 
or  bile  passages;  the  condition  of  the  heart,  too,  might  well 
have  some  bearing  upon  the  enlargement  of  the  liver.  Doubt- 
less there  was  present  some  of  that  intestinal  indigestion 
which  the  previous  consultant  had  stated  to  exist. 

^  Operations  on  the  bile  passages,  in  the  face  of  acute 
cholangitis,  should  be  avoided  or  delayed  so  far  as  may  be. 
These  acute  infections  usually  subside,  when  natural  drainage 
is  established  through  the  passages  into  the  duodenum.  Opera- 
tion in  the  face  of  an  acute  cholangitis  is  a  grave  undertaking; 
it  is  difhcult  to  isolate  completely  the  infected  passages, 
when  open,  from  the  general  peritoneal  cavity,  so  that  drainage 
of  these  passages  is  not  infrequently  followed  by  an  ugly,  and 
even  fatal,  peritonitis.  The  procedure  of  choice  is  to  wait 
for  subsidence  of  the  attack,  and  then  to  explore  and  to  estab- 
lish drainage  for  a  permanent  cure. 

^  In  the  face  of  such  an  infection  as  I  have  described, 
drainage  of  the  gall  blader  is  the  one  and  only  proper  opera- 
tive procedure.  It  is  relatively  safe  and  in  the  long  run  it 
is  curative.  I  cannot  too  strongly  deplore  the  frequent  custom 
of  terminating  such  drainage  after  three  or  four  days.  The 
main  purpose  of  the  drainage  is  to  allow  the  infected  passages 
to  quiet  down  and  recover  completely.  This  can  be  accom- 
plished best  by  maintaining  drainage  for  several  weeks  even, 
if  necessary. 

Mrs.  Marion  showed  signs  of  collapse  while  still  on  the  table, 
but  after  being  put  back  to  bed  she  rallied  well,  and  her  pulse 
during  the  day  dropped  from  140  to  106.  Greatly  to  my  satis- 
faction, she  made  an  excellent  recovery.  On  the  third  day 
her  temperature  was  running  normal,  with  a  pulse  well  under 
100.  For  many  days  she  drained  by  the  tube  about  eight 
ounces  of  bile  daily,  and  it  was  not  until  three  weeks  after  the 
operation  that  I  thought  it  wise  to  remove  the  tube.  The  tube 
sinus  closed  within  twelve  hours,  as  it  usually  does  when  drain- 
age has  been  effective  and  infection  and  inflammation  have 
subsided.  At  the  end  of  a  month  Mrs.  Marion  was  up  and 
about,  and  improving  rapidly.     I  followed  her  for  two  years, 


LIVER   AND    DUCTS.  1 33 

and  was  constantly  interested  to  learn  that  she  continued  in 
sound  health.  I  am  convinced  that  without  a  drainage  opera- 
tion she  would  have  died. 


134  SURGICAL    PROBLEMS. 

Case  44.  Mrs.  Charles  Gong  was  a  strong,  active  woman 
until  she  was  prostrated  by  illness  at  the  age  of  sixty-one, 
when  first  she  came  under  my  observation.  This  was  on  the 
I2th  of  December,  1905.  She  had  been  married  for  nearly 
forty  years,  and  had  borne  four  children;  the  youngest  was 
twenty  years  old.  From  each  one  of  her  confinements  she 
recovered  well,  but  as  she  advanced  in  life  she  complained 
of  symptoms  which  suggested  some  pelvic  disorder, —  fre- 
quent, distressing,  low  backache;  incontinence  of  urine; 
obstinate  constipation;  indefinite,  low  abdominal  pain;  much 
flatulence  and  occasional  distress  immediately  after  eating. 
At  the  age  of  forty-one  she  noticed  obscure  discomfort  in  the 
right  side  of  the  abdomen,  some  tenderness  up  and  down  the 
right  side  when  she  drew  her  corsets  tight,  occasional  unex- 
plained attacks  of  nausea  and  frequency  of  urination.  This 
increased  disturbance  had  lasted  about  a  month,  after  which 
she  went  on  as  before,  regarding  herself  as  an  unusually 
vigorous,  though  not  necessarily  an  unusually  well,  woman. 
In  September,  1905,  three  months  before  I  saw  her,  she  had 
a  sudden  unexplained  attack  of  epigastric  pain,  with  vomiting 
and  purging,  the  attack  lasting  about  six  hours,  and  again 
three  weeks  later  she  had  similar  attacks.^  Three  days  before 
my  visit  Mrs.  Gong  was  suddenly  stricken  with  another  acute 
attack  of  pain  in  the  right  hypochondrium,  with  vomiting, 
but  this  time  with  constipation  —  no  movement  of  the  bowels 
for  three  days.  On  the  next  day  there  was  nausea,  but  no  vom- 
iting, the  pain  continuing.  On  the  next  day,  the  day  before 
I  saw  her,  the  nausea  ceased,  but  almost  simultaneously  a 
marked  jaundice  suddenly  appeared,  while  the  pain  gradually 
diminished  and  disappeared.  After  this  throughout  the  day 
her  condition  continued  relatively  good,  and  all  anxiety  on  her 
account  subsided.  On  the  day  of  my  visit,  however,  and  four 
hours  before  I  saw  her,  a  sudden  alarming  collapse  supervened ; 
her  temperature  shot  up  from  100°  to  103°,  and  her  pulse 
rose  to  140;  after  an  hour  there  was  improvement.  No  pain, 
nausea  or  intestinal  disturbance  apparently  were  associated 
with  this  collapse.  The  temperature  gradually  fell  and  the 
pulse  fell,  so  that  when  I  saw  the  patient  her  temperature  was 
98.8°  and  her  pulse  92. 


LIVER   AND   DUCTS.  135 

My  examination  revealed  a  large,  robust,  flushed-looking 
woman,  distinctly  jaundiced,  with  abdomen  somewhat  dis- 
tended, very  tender  In  the  epigastrium  and  right  hypochon- 
drlum,  excruciatingly  tender  over  the  gall-bladder  region  and 
down  towards  the  appendix;  up  and  down  the  right  side  the 
skin  felt  doughy,  while  an  obscure  mass  the  size  of  a  fist 
could  be  made  out.  Indistinctly,  below  the  margin  of  the  ribs 
and  apparently  connected  with  the  liver.  The  chest  was  nega- 
tive. The  urine,  aside  from  containing  bile,  was  not  peculiar. 
An  examination  of  the  pelvis  disclosed  a  somewhat  enlarged 
retrocessed  uterus  and  an  extensively  torn  perineum,  but  this 
pelvic  condition  did  not  enter  into  our  consideration.^ 

I  felt  justified  In  concluding  that  Mrs.  Gong  was  suffering 
from  an  acute  attack  of  cholangitis,  associated  with  gallstone 
obstruction, —  obstruction,  doubtless,  in  the  common  duct. 
On  account  of  the  acuteness  of  the  situation,  I  recommended 
delay  for  a  few  days  until  conditions  should  more  nearly  ap- 
proach the  normal,  and  then  to  seek  permanent  relief  by  an 
operation.  The  patient  rallied  well  after  my  visit.  A  week 
later  her  temperature  was  running  normal,  her  jaundice  had 
disappeared  and  she  was  feeling  comfortable. 

I  heard  nothing  more  from  her  for  six  months,  when  she 
applied  to  me  for  an  operation,  at  that  time  being  apparently 
in  perfect  health.  On  my  examination  then  I  could  find 
little  except  some  obscure  resistance  In  the  region  of  the  gall 
bladder  and  some  slight  tenderness  there.  I  operated  on 
the  22d  of  June,  1906,  readily  exposing  the  gall  bladder, 
which  was  about  the  size  of  a  goose  egg,  and  when  opened 
found  to  contain  twenty-three  faceted  stones,  each  about 
as  large  as  a  chestnut.  The  ducts  lower  down  were  free,  as 
I  demonstrated  by  forcing  water  through  the  common  duct 
into  the  duodenum.  There  was  nothing  further  of  significance 
to  be  found  In  the  abdomen.  The  patient  rallied  well,  and 
three  weeks  later  went  home.  She  has  remained  in  excellent 
health.3 

^  Up  to  this  point  in  the  patient's  history  we  can  lay  our 
finger  on  nothing  definite  to  explain  the  epigastric  pain,  the 
vomiting  and  the  purging,  though  we  may  inquire  more  par- 
ticularly about  the  nature  of  those  symptoms.    The  epigastric 


136  SURGICAL    PROBLEMS. 

pain  is  said  to  have  come  on  with  great  violence  about  an  hour 
after  taking  food,  and  once  in  the  night,  several  hours  after 
eating,  in  which  case  it  passed  off  gradually,  not  suddenly. 
The  vomiting  was  associated  with  extreme  nausea  and  retch- 
ing, and  did  not  relieve  the  pain.  There  was  no  blood  in  the 
vomitus.  The  purging  occurred  some  hours  after  the  attack 
of  pain  and  vomiting ;  there  were  three  or  four  profuse,  watery 
discharges,  after  which  the  bowels  returned  to  a  natural  con- 
dition ;  there  was  nothing  in  the  discharges  to  suggest  hemor- 
rhage; in  this  connection  I  note  that  careful  examination  of 
the  vomitus  and  of  the  stools  failed  to  discover  occult  blood. 

^  Were  it  not  for  the  jaundice  the  diagnosis  would  be  ob- 
scure, and  even  with  the  jaundice  the  diagnosis  is  not  alto- 
gether clear.  One  thinks  of  acute  appendicitis,  with  complica- 
tions (subphrenic  abscess),  or  one  thinks  of  acute  disease  of  the 
bile  passages,  superimposed  upon  an  old  chronic  cholangitis, 
with  gallstones  or  of  acute  pancreatitis.  Acute  bile-passage 
disease  is  far  the  more  probable,  in  view  of  the  jaundice. 
On  the  other  hand,  in  view  of  the  patient's  age  and  the  long 
continuance  of  her  symptoms,  dating  back  altogether  twenty 
years,  it  is  within  the  realm  of  probability  that  she  may  have 
primary  malignant  disease,  with  consequent  obstruction. 
The  main  argument  against  the  latter  diagnosis  is  the  inten- 
sity of  the  pain  and  the  gravity  of  the  symptoms.  The  pain 
of  malignant  disease  of  the  bile  passages  is  not  especially 
severe,  while  the  onset  of  the  disease  is  slow  and  the  jaundice 
gradually  progressive.  In  malignant  disease,  moreover,  one 
would  not  expect  so  startling  a  collapse,  with  so  pronounced 
a  rise  of  temperature  and  pulse. 

^  The  important  teaching  of  this  case  is  the  wisdom  of  wait- 
ing for  subsidence  of  acute  symptoms  before  operating  in  gall- 
bladder disease.  Nearly  all  of  these  acute  cases  will  improve 
and  return  essentially  to  the  normal ;  then  is  the  time  to  operate 
—  between  attacks.  An  operation  done  during  the  height  of  an 
attack  is  undertaken  with  considerable  risk  to  the  patient, 
risk  of  collapse  and  risk  of  infection. 


LIVER   AND   DUCTS.  1 37 

Case  45.  Francis  Allen,  a  prosperous  farmer  living  near 
Boston,  had  been  well  known  to  me  since  his  boyhood.  He  was 
a  vigorous  out-of-doors  man,  always  apparently  in  the  best 
of  health,  though  given  somewhat  to  the  constant  use  of  al- 
coholic stimulants.  At  the  age  of  thirty-five  he  contracted 
syphilis,  for  which  he  was  thoroughly  treated  and  from  which 
he  recovered.  After  that  he  married,  and  had  two  healthy 
children.  At  the  age  of  forty-one,  on  the  30th  of  August, 
1905,  he  consulted  me  for  the  ailment  I  am  about  to  report. 

He  stated  that  for  the  past  ten  days  he  had  suffered  from 
frequent  distress  in  the  right  side  of  the  abdomen,  not  positive 
pain.  He  said  he  felt  poorly;  he  had  no  nausea,  but  a  fair 
appetite  and  regular  bowels.    There  was  no  jaundice. 

I  found  his  head,  eyes,  skin,  throat  and  nasal  passages  in 
good  condition,  and  his  chest  not  abnormal;  his  temperature 
was  normal,  his  pulse  72.  I  could  make  out  no  abdominal 
tenderness,  but  the  abdominal  wall  was  extremely  thick  and 
resistant,  A  rectal  examination  was  negative.  This  patient 
was  a  short,  stout,  thick-set  man,  weighing  about  one  hundred 
and  sixty  pounds,  clear-eyed,  alert,  highly  intelligent.  I 
got  little  out  of  the  story,  and  could  not  but  suspect  that  he 
might  have  a  gumma  of  the  liver,  for  it  was  in  the  region  of 
the  liver  that  his  pain  was  said  to  reside. 

These  various  symptoms  continued  for  several  days. 
On  the  4th  of  September  I  discovered  a  slight  mass  in  the 
region  of  the  appendix.  Three  days  later  this  mass  had  dis- 
appeared, but  he  complained  of  shifting  pain  in  the  right  hypo- 
chondriunl.  Four  days  later  again  this  pain  was  present  and 
there  was  tenderness  in  the  region  of  the  gall  bladder.  About 
that  time  I  began  talking  to  Mr.  Allen  about  an  operation,  to 
explore  the  gall  bladder  and  the  appendix,  but  he  scouted  the 
idea.  I  kept  him  quiet,  on  a  limited  diet,  with  occasional  doses 
of  Carlsbad  salts,  and  so  he  worked  along,  keeping  about  and 
not  especially  uncomfortable.  My  notes  of  the  case  are  long  and 
rather  uninteresting,  running  on  with  almost  monthly  entries 
for  about  a  year,  the  general  summary  being  that  this  patient 
had  quite  constant  sensations  of  distress  and  occasional  pain 
or  burning  in  the  region  of  the  gall  bladder,  frequently  relieved 
by  Carlsbad  salts;  that  on  two  or  three  occasions  during  this 


138  SURGICAL    PROBLEMS. 

year  he  had  distinct  pain  and  tenderness  in  the  region  of  the 
appendix,  and  that  almost  invariably,  whenever  I  saw  him  or 
talked  with  him,  he  confessed  to  a  sensation  of  tenderness  in 
the  epigastrium  and  right  hypochondrium.  During  this  period 
I  had  him  see  consultants  also,  who  agreed  that  he  was  suffer- 
ing from  some  obscure  ailment  of  an  infective  character,  but 
they  were  unable  to  make  a  positive  diagnosis.  Sometimes 
he  would  have  a  slight  rise  of  temperature  to  100°  or  101°; 
on  two  different  occasions  he  went  to  the  Virginia  Hot  Springs, 
but  without  effect,  except  to  have  his  head  filled  with  patho- 
logic and  therapeutic  clap-trap  by  friends  he  made  there. 
On  the  30th  of  August,  1907,  after  affairs  had  gone  on  in 
this  way  for  about  a  year,  Mr.  Allen's  physician  in  the  coun- 
try was  called  to  him  at  midnight.  He  found  the  patient 
in  the  midst  of  an  acute  attack  of  appendicitis;  very  tender 
over  the  appendix,  with  spasm  of  the  rectus;  temperature  101°, 
pulse  96.  These  symptoms  subsided  entirely  on  a  course  of 
starvation  treatment.^ 

I  now  felt  myself  justified  in  urging  upon  Mr.  Allen  the 
imperative  necessity  of  an  exploratory  operation.  I  had 
watched  him  for  more  than  a  year,  and  I  saw  no  prospect  for 
him  except  permanent  invalidism,  unless  something  radical 
were  done.  He  consented.  In  view  of  the  twofold  nature  of 
his  symptoms,  I  determined  on  a  double  operation.  I  opened 
down  first,  through  a  small  incision,  upon  his  appendix,  which 
I  found  kinked,  adherent  and  injected;  I  removed  the  appen- 
dix accordingly;  the  evidence  of  a  chronic  appendicitis  was 
clear.  I  then  explored  the  epigastrium  and  right  hypochon- 
drium, through  a  separate  incision.  I  found  the  gall  bladder 
of  normal  size,  thin-walled,  full  of  a  rather  pale  bile;  there 
were  no  stones  in  the  gall  bladder,  nor  were  there  stones  in 
the  bile  passages.  On  exploring  further,  however,  I  discovered 
the  head  of  the  pancreas  to  be  hard  and  to  contain  a  mass 
which  felt  about  as  large  as  a  hen's  egg, —  chronic  pancreatitis.^ 

^  The  experienced  reader  may  well  have  drawn  his  own 
conclusions  by  this  time  regarding  the  ailment  from  which 
Mr.  Allen  suffered.  He  was  now  forty-two  years  old,  and 
had  had  a  series  of  distinct  attacks  of  pain,  limited  to  two 
distinct  regions.     One  talks  knowingly,  then,  of  appendicitis 


LIVER   AND   DUCTS.  139 

and  of  gallstones,  and  reasonably.  These  two  conditions 
are  frequently  associated,  sometimes  because  of  an  extending 
infection,  sometimes  coincidentally.  A  life-long  habit  of 
alcoholism  is  thought  by  many  physicians  to  be  conducive 
to  both  ailments, 

^The  ordinary  cause  for  chronic  pancreatitis  is  looked  for 
in  some  obstruction  of  the  pancreatic  ducts,  or  of  the  common 
duct,  or  of  the  ampulla  of  Vater.  In  Mr.  Allen's  case  it  is 
probable  that  his  habits  of  life  and  his  former  syphilis  led  to 
a  chronic  obstruction  at  the  ampulla.  Failure  to  find  disease 
of  the  bile  passages,  after  such  a  history  as  I  have  given,  should 
surprise  no  experienced  surgeon.  A  long-continued  cholangi- 
tis may  well  give  rise  to  a  chain  of  symptoms  suggesting  gall- 
stones, even  though  no  gallstones  be  present.  In  operating 
upon  the  bile  passages  I  always  warn  the  patient  and  his  family 
that  gallstones  may  not  be  found,  but  that  proper  drainage 
of  the  bile  passages  in  any  case  is  essential. 

The  treatment  in  this  case  was  obvious,  —  drainage  of  the 
bile  and  pancreatic  passages.  This  drainage  is  easily  secured 
and  maintained  through  cholecystostomy, —  a  tube  sewed  into 
the  gall  bladder.  Accordingly,  I  carried  out  this  treatment, 
draining  the  gall  bladder  by  a  tube  through  a  stab  wound 
about  two  inches  to  the  right  of  the  principal  incision,  which 
was  sewed  up  tightly. 

Mr.  Allen  rallied  promptly  from  his  operation,  and  went  on 
to  a  complete  recovery.  His  appendix  symptoms  disappeared, 
of  course,  while,  much  to  my  relief  and  to  his  own  satisfaction, 
his  epigastric  disturbance  never  returned.  The  drainage  was 
carried  on  for  three  weeks,  when  the  tube  was  removed  and 
the  sinus  allowed  promptly  to  close.  He  recovered  his  health 
perfectly  in  the  course  of  six  weeks,  and  has  been  sound  and 
vigorous  ever  since. 


140  SURGICAL    PROBLEMS. 

Case  46.  Occasionally  it  falls  to  the  lot  of  every  surgeon 
to  operate  on  a  patient  devoid  of  what  we  call  "  resisting 
powers."  Probably  a  careful  study  of  the  opsonic  index 
would  give  us  some  light  on  the  prognosis  for  operating,  but 
in  spite  of  such  aids,  and  in  spite  of  "  low  vitality,"  we  are 
frequently  forced  to  operations  which  we  would  gladly  avoid. 

The  case  of  Mrs.  Orr  is  in  point.  She  was  forty  years  of 
age  when  I  saw  her  on  the  15th  of  December,  1908;  the 
mother  of  three  children,  her  health  had  always  been  good 
up  to  the  preceding  August.  She  was  indeed  peculiarly  free 
from  the  ailments  common  to  overworked  married  women. 
Though  never  extremely  robust,  she  had  always  regarded  her- 
self as  well.  She  had  suffered  from  none  of  the  serious  infec- 
tions which  commonly  lower  resistance ;  nevertheless,  she  was 
one  of  those  persons  of  whom  the  family  physician  says 
that  she  is  a  poor  surgical  risk.  When  I  was  called  to  see  her 
in  consultation  in  December  I  heard  the  following  story  of 
the  previous  four  months,  beginning  with  the  20th  of  August: 

She  had  had  twelve  attacks  of  pain,  at  intervals  of  a 
week  or  more,  in  the  right  hypochondrium ;  the  pain  would 
come  on  suddenly,  and  would  last  from  six  hours  to  three  days ; 
it  was  always  excruciating  and  abated  slowly ;  it  seemed  to  be 
brought  on  by  exertion;  it  was  not  associated  with  nausea, 
vomiting  or  irregularity  of  the  bowels;  it  left  the  patient 
exhausted;  at  no  time  during  these  previous  attacks  had 
jaundice  been  observed;  during  the  period  of  these  attacks 
Mrs.  Orr  had  lost  twenty-five  pounds  in  weight.  My  con- 
sultant informed  me  that  the  present  attack  had  lasted  two 
days  when  I  was  called,  and  was  still  in  progress.  The  pain 
came  on  in  paroxysms  and  was  agonizing,  requiring  half  a 
grain  or  more  of  morphia  to  quiet  it;  then  would  succeed 
remission,  followed  by  another  paroxysm.  For  twenty-four 
hours  this  patient  had  been  growing  yellow,  the  conjunctivae 
and  skin  being  obviously  stained.  The  pain  was  beneath  the 
right  costal  margin,  in  the  neighborhood  of  the  gall  bladder, 
but  shot  through  also  to  the  right  scapular  region.^ 

Mrs.  Orr  appeared  as  an  intelligent  woman,  abnormally 
thin  and  haggard.  Examination  of  her  abdomen  was  easy. 
In  the  region  of  the  gall  bladder  there  was  a  tender  mass. 


LIVER   AND   DUCTS.  I4I 

apparently  about  the  size  of  a  Bartlett  pear.  It  could  be 
grasped  between  the  hands  in  front  and  back,  but  did  not 
suggest  a  kidney  in  size  or  position.  There  was  also  exquisite 
tenderness  in  the  epigastrium,  along  the  course  of  the  bile 
ducts.  The  patient  was  markedly  jaundiced,  while  her  scanty 
urine  contained  bile  and  albumen. 

This  is  the  sort  of  case  which  in  my  judgment  should  be 
treated  on  the  expectant  plan.  The  profound  prostration, 
associated  with  jaundice,  renders  grave  the  outlook  for  an 
immediate  operation ;  one  fears  shock,  pneumonia  and  hemor- 
rhage, hemorrhage  especially,  as  bile  in  the  blood  delays 
coagulation  often  for  ten,  or  even  fifteen,  minutes. 

One  week  later  Mrs.  Orr's  condition  had  improved  very 
much;  her  jaundice  had  practically  disappeared,  pain  had 
ceased  and  she  was  feeling  well  and  happy,  though  she  had 
by  no  means  regained  her  normal  strength.  I  then  operated, 
and  found  a  condition  which  I  had  not  foreseen ;  the  enlarged 
gall  bladder  was  there,  larger  than  I  expected ;  it  was  greatly 
thickened,  but  its  capacity  was  not  much  more  than  the  nor- 
mal; the  cystic  duct  was  nearly  obliterated;  beyond  the  cystic 
duct  I  could  feel  nothing;  the  common  duct  seemed  to  be 
normal  and  to  contain  no  stones;  the  head  of  the  pancreas 
and  the  ampulla  of  Vater  were  normal  to  the  touch. ^ 

^  Be  it  remembered  that  the  radiating  pain  due  to  gallstones 
in  the  gall  bladder  is  towards  the  right  shoulder,  but  the  radiat- 
ing pain  due  to  gallstones  in  the  common  duct  is  towards  the 
back  and  scapular  regions.  This  last  phenomenon  In  the  case 
of  Mrs.  Orr,  associated  as  It  was  with  jaundice,  made  reasona- 
bly certain  the  diagnosis  of  obstruction  to  the  common  duct. 

^  How  shall  we  explain  the  recurring  jaundice,  the  obvious 
obstruction  to  the  common  duct,  the  pain  radiating  to  the 
scapular  region,  the  greatly  thickened  gall  bladder,  showing 
a  disease  of  many  years  standing  probably?  The  pathological 
history  of  Mrs.  Orr  probably  was  something  quite  different 
from  the  clinical  history,  and  I  doubt  if  the  family  physician 
or  I  myself  pursued  our  clinical  investigations  far  enough. 
Chronic  Inflammation  of  the  gall  bladder  and  passages  often 
exists  for  months  and  years  without  giving  rise  to  the  clinical 
symptoms  of  gallstones.  Patients  suffering  from  such  chronic 
disease  become  dyspeptics,  with  small  appetites,  with  flatu- 
lence, constipation,  headaches,  and  more  or  less  nausea,  while 


/ 


142 


SURGICAL    PROBLEMS. 


their  vigor  is  diminished,  and  they  sink  into  a  condition  often  of 
obscure,  chronic  invalidism.  Such  a  state  of  affairs,  however, 
is  not  always  present  with  a  chronic  inflammation  of  the  gall 
bladder.  The  symptoms  and  the  condition  vary  within  wide 
margins.  Evidently  Mrs.  Orr  was  able  to  lead  her  life  and 
perform  her  usual  work  without  much  disturbance  from  her 
gall-bladder  disease.  The  sudden  increase  of  symptoms, 
associated  with  great  pain  and  prolonged  prostration,  may 
have  been  due  either  to  the  collecting  of  small  stones  in  the 
common  duct,  which  were  from  time  to  time  passed  on  into 
the  duodenum,  or  to  extensive  adhesions,  grasping  and 
partially  obstructing  the  common  duct, —  adhesions  due  to 
the  disease  of  the  gall  bladder.  My  conviction  is  that  this  last 
explanation  will  satisfy  us  in  the  case  of  Mrs.  Orr.  Nowhere 
could  I  find  evidence  of  stones,  either  in  the  hepatic  radicles 
or  in  the  common  duct. 

The  further  procedure  in  this  case  was  obvious, —  removal 
of  the  gall  bladder.  Drainage  of  such  a  diseased  organ  would  be 
absolutely  useless;  it  would  fail  to  remove  the  symptoms  and 
it  would  put  no  limit  to  the  disease ;  cholecystostomy,  or  drain- 
age, is  applicable  to  gall  bladders  of  a  more  nearly  normal 
structure ;  conversely,  cholecystectomy,  or  removal  of  the  gall 
bladder,  is  dangerous,  not  so  much  from  the  nature  of  the 
operation  itself  as  because  cholecystectomy  is  called  for  in 
cases  of  severe  advanced  disease  generally,  in  which  any 
operation  is  serious.  In  the  case  of  Mrs.  Orr  we  see  repeated 
the  grounds  for  the  old  argument  that  gall-bladder  disease 
should  not  be  allowed  to  go  on  indefinitely,  but  should  be  ter- 
minated by  operation,  if  the  chronic  inflammation  has  become 
fixed  and  troublesome.  I  removed  the  gall  bladder  and 
drained  carefully  the  whole  area,  stitching  with  fine  gut  a  tube 
into  the  stump  of  the  cystic  duct.  In  spite  of  our  speed  and 
great  care,  however,  the  patient  fell  into  a  condition  of  pro- 
found shock,  and  showed  little  tendency  to  rally  after  her 
ether,  in  fact  she  never  rallied.  She  recovered  consciousness, 
but  the  next  day  her  pulse  was  small  and  thready,  with  a  rate 
of  140.  So  she  continued  for  three  days.  There  was  slight  but 
persistent  nausea  but  no  abdominal  distention,  and  the  bowels 
moved  well.  We  did  all  in  our  power  to  overcome  the  shock, — 
by  transfusion,  by  posture,  by  carefully  employed  doses  of 


LIVER  AND   DUCTS,  I43 

strychnia,  but  all  to  no  purpose;    she  failed  gradually  and 
finally  died  in  shock. 

One  reports  such  a  case  as  this  with  hesitation  and  regret, 
and  one  asks,  What  lesson  does  it  teach?  I  believe  it  does 
not  warn  us  against  operating  in  these  desperate  cases.  It 
was  clear  to  all  of  us  concerned  that  without  an  operation 
at  the  appropriate  period  Mrs.  Orr  could  live  but  a  short  time, 
and  that  the  balance  of  her  life  would  be  one  of  the  utmost 
wretchedness.  As  I  review  the  case,  I  feel  that  our  only  mis- 
take was  in  operating  within  a  week  of  a  serious  attack  of 
pain.  If  she  could  have  been  carried  on  to  a  state  of  better 
health,  it  is  possible  that  an  operation  a  month  later  would 
have  been  successful.  All  this  is  hypothetical,  however, 
for  in  fact  her  attacks  of  pain  were  coming  on  at  intervals 
of  about  ten  days.  The  case  is  certainly  worthy  of  study  and 
discussion  alike  by  general  practitioners  and  by  surgeons. 


144  SURGICAL    PROBLEMS. 

Case  47.  A  well-known  and  competent  internist  asked 
me  to  see  Mrs.  Nathan  O'Nutt  on  the  3d  of  December,  1906. 
This  physician  had  known  the  patient  and  her  family  for  sev- 
eral years,  and  had  followed  with  solicitude  her  various  ail- 
ments. When  I  first  saw  Mrs.  O'Nutt,  she  was  sixty  years  of 
age.  She  had  borne  three  children,  who  were  grown.  She 
had  been  in  ill-health  for  many  years.  I  doubt  if  she  had  ever 
been  strong,  for  she  belonged  to  that  type  which  we  have  come 
to  regard  as  typical  sufferers  from  abdominal  ptosis, —  long- 
waisted,  with  a  sharp  declination  of  the  floating  ribs  and  an 
extremely  short  space  between  the  ribs  and  the  iliac  crests 
(costo-iliac  space).  While  there  was  nothing  of  special 
significance  in  her  past  history,  I  learned  that  she  had  always 
been  a  dyspeptic  and  had  suffered  much  from  sundry  pains 
in  the  abdomen,  chest  and  limbs,  especially  pain  in  the  left 
chest,  which  suggested  zoster.  Her  dyspepsia  had  not  been 
of  a  characteristic  type ;  she  told  merely  of  some  distress  at 
varying  periods  after  eating,  of  chronic  constipation  and  of 
indefinite  abdominal  pains;  her  appetite  had  been  small  for 
many  years,  and  she  was  not  aware  of  having  lost  flesh  re- 
cently. Her  physician  told  me  that  he  regarded  her  for  years 
as  a  "  nervous  dyspeptic,"  who  must  be  patched  along  in  some 
way.  He  stated  further  that  two  weeks  before  I  saw  her  she 
had  had  a  moderately  severe  attack  of  pain  in  the  epigastrium, 
which  was  relieved  by  a  sixth  of  a  grain  of  morphia,  after 
six  hours ;  again  a  week  before  I  saw  her  she  had  a  similar 
attack,  and  another  after  four  days ;  this  last  was  associated 
with  nausea  and  constipation.  There  had  been  no  vomiting, 
no  jaundice  and  no  fever.  He  reported  the  urine  as  not 
abnormal.^ 

^  Up  to  this  point  the  history  suggests  disease  of  the  gall 
ducts;  especially  we  note  the  characteristic  epigastric  pain 
recurring  with  nausea,  added  to  the  long  history  of  "  nervous 
dyspepsia."  A  physical  examination,  however,  threw  some 
surprisingly  new  light  on  the  case. 

I  found  Mrs.  O'Nutt  to  be  a  tall,  thin,  emaciated  woman, 
with  a  scaphoid  abdomen.  I  could  make  nothing  out  of  the 
chest  or  pelvis;  there  was  no  tenderness  in  the  epigastrium. 
On  palpating  bimanually  in  the  right  flank,  however,  I  en- 


LIVER  AND   DUCTS.  I45 

countered  at  once  a  mass  on  a  level  with  the  navel  and  in  the 
vicinity  of  the  kidney  —  a  mass  about  the  size  of  a  man's  fist, 
movable,  tender,  hard,  apparently  associated  with  the  right 
kidney;  it  could  be  felt  readily  by  the  left  hand  palpating  the 
loin.  In  spite  of  the  negative  evidence  obtained  from  the  urine 
I  concluded  that  we  had  to  deal  with  a  tumor  of  the  kidney,  pre- 
sumably sarcoma,  —  not  hypernephroma,  as  hypernephroma 
of  long  standing  and  considerable  size  is  almost  invariably 
complicated  by  metastases  in  some  of  the  long  bones,  notably 
the  clavicles.  Accordingly,  I  advised  an  exploratory  opera- 
tion, with  a  view  to  removing  the  kidney. 


Two  days  later  I  operated,  cutting  down  upon  the  right 
kidney  through  the  loin.  Somewhat  to  my  surprise,  I  found 
the  kidney  in  normal  position,  though  it  was  distinctly  mova- 
ble up  and  down,  but  it  was  in  no  way  diseased;  indeed,  it 
was  a  small  kidney,  and  not  peculiar  in  appearance.  Lying 
upon  it,  however,  so  as  to  form  with  it  a  single  mass  apparently, 
there  was  felt  a  distinct  tumor  which  could  be  moved  easily 
up  into  the  epigastrium,  leaving  the  kidney  in  its  place. 
Enlarging  the  opening  in  the  loin,  I  then  exposed  the  peri- 
toneum, entered  the  peritoneal  cavity  and  sought  the  second 
tumor,  which  proved  to  be  an  enlarged  gall  bladder,  distended 
to  the  size  of  a  child's  fist  and  extremely  motile.  I  opened 
the  gall  bladder  and  explored  the  ducts.  The  gall  bladder  was 
not  especially  peculiar  in  appearance,  except  that  it  contained 
a  huge  calculus,  molded  almost  exactly  to  the  shape  of  the 
gall  bladder,  with  a  pedicle  running  down  into  the  cystic  duct. 
By  the  side  of  this  calculus  lay  another  small  stone,  faceted 
and  about  the  size  of  a  filbert.  The  larger  stone,  when  re- 
moved, seemed  to  be  of  enormous  size,  and  was  actually  about 
as  large  as  an  average  hen's  egg.  I  drained  the  gall  bladder 
through  a  stab  wound. 

The  patient  made  an  excellent  recovery.  On  the  removal 
of  the  tube,  at  the  end  of  ten  days,  the  sinus  closed  promptly, 
and  the  subsequent  convalescence  was  uneventful.  I  was 
interested  to  follow  the  subsequent  history  of  Mrs.  O'Nutt. 
One  year  after  the  operation  she  came  to  see  me,  feeling  well, 
but  complaining  that  she  had  an  occasional  soreness  in  the  right 
side.    On  examining  her  carefully  I  discovered  that  the  right 


146  SURGICAL    PROBLEMS. 

kidney  was  still  movable,  and  traveled  up  and  down  the  ab- 
domen with  the  greatest  freedom.  A  well-fitting  corset-belt 
relieved  this  trouble,  and  I  am  now  told  that  the  patient  is  in 
better  health  than  for  many  years  past. 

The  case  is  interesting  from  the  point  of  diagnosis.  The 
physician  who  operates  infrequently,  or  seldom  sees  post- 
mortem examinations,  is  apt  to  forget  that  the  right  kidney 
lies  high  behind  the  duodenum  and  in  fairly  close  relation 
with  the  gall  bladder  normally.  For  this  reason,  when  inves- 
tigating digestive  disorders,  and  especially  disorders  asso- 
ciated with  pain  in  the  epigastrium,  one  should  always  bear 
in  mind  the  possibility  of  some  disease  of  the  kidney ;  further- 
more, when  a  right  kidney  is  motile  and  moves  readily  up 
and  down  the  right  side,  one  should  remember  that  it  does  not 
necessarily  escape  from  its  proximity  to  an  enlarged  gall 
bladder,  which,  when  weighted  with  stones,  may  well  follow 
a  kidney  down  into  the  loin. 


LIVER   AND   DUCTS.  1 47 

Case  48.  The  case  of  Matilda  O'Brien,  though  not  unusual, 
was  interesting  and  instructive.  I  was  asked  to  see  her  in 
January,  1910,  and  was  told  the  following  story:  The  patient 
said  she  was  forty-eight  years  of  age;  she  appeared  to  be 
sixty-five.  She  was  housekeeper  for  a  gentlemen  well  known 
to  me,  who  regarded  her  almost  as  a  mother  and  showed  the 
greatest  solicitude  for  her  comfort.  She  had  always  been  an 
active,  hard-working  woman.  Her  previous  history  was  ex- 
cellent. She  was  said  to  have  passed  the  menopause  two  years 
before.  Her  present  illness  was  thought  to  run  back  some  six 
months.  In  July,  1909,  she  first  consulted  the  physician  who 
called  me  in.  She  went  to  see  him  regarding  certain  dyspeptic 
symptoms,  loss  of  appetite  especially,  and  distress  immediately 
after  food.  He  found  that  the  distress  was  easily  relieved 
by  alkalies.  He  treated  her  expectantly,  therefore,  for  about 
three  months,  when  there  was  noticed,  suddenly,  jaundice, 
developing,  apparently,  in  twenty-four  hours.  There  was 
no  pain  then  or  at  any  subsequent  time ;  there  was  no  abdomi- 
nal tenderness;  the  principal  and  almost  the  only  complaint 
was  loss  of  appetite.  My  consultant,  at  first,  sent  Miss  O'Brien 
to  a  nearby  hospital,  where  she  was  dieted  for  a  month,  with- 
out special  change  in  her  condition.  She  then  came  home, 
where  she  had  lain  in  bed  for  the  three  weeks  previous  to  my 
visit,  and  was  said  to  be  a  good  deal  improved  over  her  state 
of  three  months  before.  Though  her  appetite  was  small, 
she  had  ceased  to  lose  weight;  she  had  no  pain,  no  fever, 
indeed  no  symptoms  whatever,  except  the  anorexia  and  the 
persistent  jaundice  which  had  lasted  now  for  three  months.^ 

On  examining  this  patient  I  found  her  to  be  an  extremely 
emaciated,  but  placid  and  contented,  old-looking  woman, 
thin  and  wrinkled.  Her  tongue  was  moist  and  slightly  furred, 
the  conjunctivse  and  skin  were  markedly  jaundiced,  the  jaun- 
dice being  almost  lemon  yellow  and  said  not  to  vary  in  char- 
acter from  month  to  month.  The  urine  was  loaded  with  bile. 
I  could  feel  nothing  wrong  in  the  pelvis  or  abdomen  except 
a  slightly  enlarged  liver;  the  heart  and  lungs  were  not  pecu- 
liar; there  was  no  tenderness  anywhere;  indeed,  there  were  no 
other  physical  signs.  I  was  informed  that  other  surgeons  had 
seen  this  patient,  and  their  opinion  was  that  she  was  suffering 


148  SURGICAL    PROBLEMS. 

from  malignant  disease  of  the  liver.  That  diagnosis  was  my 
own  also,  but  I  told  the  patient's  employer  that  we  could  not 
rule  out  the  possibility  of  a  chronic  pancreatitis.  When 
pressed  to  suggest  a  remedy,  or  some  method  of  relief,  I 
could  only  say  that  I  regarded  an  exploratory  operation  as 
justifiable.  Of  course  nothing  could  be  done  for  a  cancer  of 
the  liver,  but  it  might  be  that  chronic  pancreatitis  alone 
existed,  in  which  case  drainage  of  the  bile  ducts  by  cholecys- 
tostomy;  or  possibly  a  permanent  drainage  by  cholecystenter- 
ostomy,  might  be  of  service. 

Accordingly,  I  had  the  patient  transferred  to  a  hospital, 
for  observation ;  especially,  I  wished  to  note  the  clotting  time 
of  the  blood.  In  the  face  of  the  persistent  jaundice,  I  was  sure 
that  a  present  operation  would  be  complicated  by  troublesome 
or  possibly  fatal  hemorrhage,  and  I  wished,  if  possible,  to 
eliminate  this  contingency. 

At  the  time  of  her  entering  the  hospital  Miss  O'Brien  was 
examined  by  Dr.  Cleaveland  Floyd,  who  made  the  following 
statement  regarding  her  blood:  "The  coagulation  time 
is  about  twelve  minutes;  hemoglobin  60%;  red  corpuscles 
3*576,000,  whites  6,200."  The  further  analysis  I  omit,  except 
to  state  that  blood  platelets  were  increased.  In  order  to  shorten 
the  coagulation  time,  I  immediately  put  the  patient  on  5-grain 
doses  of  thyroid  extract,  given  twice  a  day.  She  took  this 
remedy  for  nine  days,  at  the  end  of  which  time  Dr.  Floyd 
examined  her  again  and  made  the  following  report:  "  Coagu- 
lation began  at  the  end  of  two  and  one-half  minutes,  and  was 
well  marked  at  the  end  of  five  and  one-half  minutes;  blood 
of  better  consistency  than  when  examined  ten  days  ago,  and 
serum  ring  less  marked."^ 

During  this  period  of  rest  at  the  hospital  the  patient  was 
happy  and  comfortable,  and  her  appetite  improved  somewhat. 
Three  days  after  Dr.  Floyd's  last  report  I  operated,  by  a  short 
incision  through  the  right  rectus  muscle.  Immediately  on 
opening  the  abdominal  cavity  I  exposed  a  liver  enlarged  and 
studded  with  characteristic  nodules  of  cancer.  I  carried  the 
exploration  no  further  than  to  determine  that  the  gall  bladder 
was  full  of  stones  and  that  a  definite  mass,  malignant  to  the 
feel,  existed  in  the  pylorus.    The  obvious  diagnosis  was,  there- 


LIVER   AND   DUCTS.  1 49 

fore,  cancer  of  the  liver,  probably  secondary  to  cancer  of  the 
pylorus.^ 

^  A  history  of  chronic  jaundice  and  loss  of  appetite  alone, 
associated  with  the  inevitable  emaciation,  suggests  first  malig- 
nant disease  of  the  liver,  presumably  primary.  Nearly  all  other 
causes  of  jaundice  are  associated  with  pain,  of  varying  degree, 
especially  inflammatory  disease  of  the  ducts,  with  gallstones. 
Catarrhal  jaundice  is  an  acute  and  relatively  short  affair. 
Chronic  inflammatory  diseases  involving  the  liver  tissue 
itself,  while  causing  jaundice,  cause  evidence  of  portal  ob- 
struction also,  but  there  was  no  such  evidence  in  the  case  of 
Miss  O'Brien.  A  chronic  pancreatitis  is  evidenced  by  a  thick- 
ening and  hardening  usually  of  the  head  of  the  pancreas  and 
a  compression  of  the  common  duct,  which  in  the  great  majority 
of  cases  passes  through  the  head  of  the  pancreas. 

^  This  shortening  of  coagulation  time  by  the  use  of  thyroid 
extract  has  been  a  favorite  method  with  me  for  some  three 
years.  In  my  experience  it  is  more  certain  and  more  quickly 
effective  than  the  calcium  chloride  and  calcium  lactate  treat- 
ment, and  more  certain  though  not  always  so  promptly  appar- 
ent, as  the  sera  treatment.  A  blood  coagulating  in  twelve 
minutes  may  well  threaten  troublesome  and  obstinate  hemor- 
rhage; a  blood  coagulating  within  five  and  one-half  minutes  is 
within  normal  limits. 

^  After  an  exploratory  operation  which  discloses  malignant 
disease  our  endeavor  must  be  to  get  the  patient  up  and  about 
again  as  quickly  as  possible.  To  this  end  we  explore  through 
a  small  incision,  and  close  the  incision  subsequently  with 
through-and-through  stitches  not  involving  the  skin,  stitches 
preferably  of  silkworm  gut,  or  even  of  silver.  A  patient  in 
fair  vigor  may  then  be  gotten  out  of  bed  at  the  end  of  three 
or  four  days,  and  may  be  sent  home  at  the  end  of  a  week  or 
ten  days. 

Miss  O'Brien  went  home  in  good  condition,  and  lingered 
on  for  some  four  months  in  comfort;  eventually  she  died  of 
exhaustion.  The  lesson  from  this  case  rests  in  the  difficulty 
of  positive  diagnosis  and  in  the  fact  that  a  delayed  blood 
coagulation  time  may  be  shortened  by  the  use  of  thyroid 
extract.  Miss  O'Brien  was  not  particularly  disturbed  by  the 
brief  operation ;  the  diagnosis  was  positively  settled ;  and  her 
friends,  if  not  herself,  were  given  the  melancholy  satisfaction 
of  knowing  the  inevitable  outcome  of  her  illness. 


GESTATION. 

Case  49.  Mrs.  Jacob  Schneider  had  been  married  sixteen 
months  when  I  was  called  to  see  her  on  the  22d  of  Feb- 
ruary, 1906.  She  was  then  twenty-four  years  old,  and  was 
the  mother  of  a  child  six  months  old.  She  had  reasonable 
health  during  her  girlhood,  though  she  had  always  suffered 
somewhat  from  painful  and  Irregular  menstruation,  from 
"  acid  stomach  "  and  from  constipation.  Immediately  after 
her  marriage  she  developed  a  train  of  symptoms  suggesting 
syphilis, —  sores  on  various  parts  of  the  body,  skin  eruptions, 
some  falling  of  the  hair  and  frequent  headaches.  So  far  as  I 
could  ascertain,  however,  these  symptoms  disappeared  in  the 
course  of  two  or  three  months  without  treatment,  so  that  their 
exact  nature  does  not  appear.  She  and  her  husband  were 
rather  ignorant  people,  and  their  story  was  not  altogether 
coherent.  Her  baby  was  born  at  term,  and  was  a  vigorous 
child,  without  evidence  of  a  specific  infection.  Four  months 
after  her  confinement  Mrs.  Schneider  began  to  have  regular 
menstrual  periods,  which  continued.  Her  last  period,  two 
weeks  before  my  visit,  was  in  no  way  peculiar.  After  the  birth 
of  her  child  she  gained  in  weight  and  her  general  health 
improved,  so  that  she  regarded  herself  as  very  strong  and  well. 
Twenty-four  hours  before  I  saw  her,  while  about  her  house- 
work, she  was  seized  suddenly  with  severe  general  abdominal 
pain,  agonizing,  prostrating.  She  was  carried  to  bed,  and  had 
lain  there  in  great  distress  ever  since.  During  this  period  of 
hours  her  bowels  had  not  moved,  in  spite  of  frequent  enemata. 
Her  physician,  who  called  me,  stated  that  her  condition  had 
not  given  any  anxiety  until  within  an  hour.  Within  the  hour 
however,  there  had  come  on  a  sudden  extreme  collapse,  so  that 
the  patient  became  apparently  moribund,  with  a  pulse  of  150. 
With  this  collapse  there  appeared  a  trifling  hemorrhage  from 
the  uterus;^  abdominal  distention  also  had  come  on  in  the  past 
hour,  so  that  the  abdomen  was  unnaturally  full  and  tympani- 
tic.   He  stated  that  on  examining  the  pelvis  bimanually  he 

151 


152  SURGICAL    PROBLEMS. 

could  find  nothing  abnormal,  that  the  uterus  was  small, 
movable  and  in  good  position,  but  that  the  abdominal  ten- 
derness prevented  his  making  a  satisfactory  examination. ^ 

I  saw  this  woman,  as  I  have  stated,  twenty-four  hours  after 
the  onset  of  her  serious  symptoms.  I  found  her  in  such  col- 
lapse that  a  thorough  examination  was  impossible.  The 
abdomen  was  everywhere  exquisitely  tender,  especially  in 
the  right  ovarian  region ;  she  was  greatly  distended  and  tym- 
panitic, the  right  rectus  being  rigid  and  in  spasm.  Owing 
to  her  pain,  tenderness  and  collapse  I  could  make  out  nothing 
by  a  pelvic  examination.  Her  temperature  was  99.6°  and 
her  pulse  140;  leukocyte  count,  15,000. 

I  transferred  her  safely  and  quickly  to  a  neighboring  hos- 
pital, and  proposed  a  rapid  exploratory  operation.  This 
was  not  at  first  consented  to,  until  another  surgeon  had  seen 
her  in  consultation.  One  of  my  colleagues  was  therefore 
summoned,  who  regarded  Mrs.  Schneider's  state  as  extremely 
desperate,  too  grave  for  any  operation.  Accordingly,  we 
delayed  for  an  hour;  at  the  end  of  that  time  the  patient's 
condition  had  improved  somewhat,  and  we  agreed  that  an 
exploration  was  feasible.^  I  quickly  opened  the  abdomen 
through  the  right  rectus  muscle,  and  discovered  the  belly 
full  of  clots  and  fluid  blood.  Rapidly  turning  out  some  of  this 
material  from  the  pelvis,  I  found  the  right  tube  extensively 
ruptured,^  but  not  bleeding.  A  small  fetal  sac  one  inch  long 
lay  by  its  side.  I  quickly  tied  ofT  the  tube,  turned  out  the 
clots,  washed  out  the  abdomen  with  hot  salt  solution  and  got 
the  patient  back  to  bed  in  a  very  few  minutes.  The  uterus 
was  movable  and  in  good  condition,  the  left  tube  and  ovary 
were  normal.  After  a  stimulating  infusion  of  hot  salt  solution 
the  patient  rallied  satisfactorily,  and  went  on  subsequently 
to  a  good  convalescence.  At  the  end  of  two  weeks  she  was 
discharged,  well. 

1  The  main  features  in  the  history  up  to  this  point  are  the 
agonizing  pain  and  the  profound  collapse.  Sudden,  over- 
whelming, agonizing  pain  in  the  belly  is  due  commonly  to 
the  rupture  of  some  viscus.  The  perforation  of  a  duodenal 
ulcer  causes  overwhelming  pain,  though  the  collapse  in  that 
case  is  not  great  at  first.    The  pain  and  collapse  of  pancreatic 


GESTATION.  153 

apoplexy  are  overwhelming.  Rupture  of  the  bowel  causes 
great  pain,  as  does  rupture  of  the  stomach,  though  the  pain 
is  not  profound  always.  Perforation  of  an  appendix  is  often 
followed  by  relief  of  pain,  and  the  collapse  of  appendicitis 
is  slow.  In  other  words,  profound  collapse  immediately 
associated  with  pain  signifies  almost  always  a  hemorrhage. 
There  are  two  conditions  which  invariably  present  the  picture 
of  pain  and  collapse  which  I  have  drawn, —  the  rupture  of 
an  extra-uterine  pregnancy  and  pancreatic  apoplexy. 

^  The  uterus  of  extra-uterine  pregnancy  is  not  commonly 
normal  in  size.  The  careful  investigation  of  such  a  pregnancy 
should  demonstrate  a  somewhat  enlarged  uterus,  boggy, 
with  a  mass  to  be  felt  at  its  side  in  the  position  of  one  or  the 
other  tube.  Moreover,  a  woman  the  subject  of  extra-uterine 
pregnancy  will  almost  always  describe  some  slight  irregular 
flowing. 

^  The  question  whether  or  not  to  explore  in  the  face  of  the 
extreme  collapse  of  a  ruptured  tubal  pregnancy  is  not  alto- 
gether settled.  Formerly  there  were  those  who  urged  imme- 
diate operation,  and  there  were  those  who  opposed  such  action, 
and  would  wait  until  the  patient  had  rallied  from  her  hemor- 
rhage. I  believe  that  most  experienced  surgeons  to-day 
would  follow  the  course  we  adopted,  being  guided  by  their 
own  judgment.  No  man  would  operate  on  a  moribund  patient; 
at  the  same  time,  the  danger  of  recurring  hemorrhages  is  too 
great  to  permit  of  long  delay.  It  is  my  habit,  therefore,  to 
wait  for  a  short  time,  without  giving  stimulants,  merely 
allowing  the  patient  to  rally  from  her  lowest  point.  I  do  not 
dare  even  to  try  the  expedient  of  using  the  pneumatic  suit, 
or  bandaging  the  limbs,  as  that  course  of  treatment  has  been 
known  to  start  up  fresh  hemorrhage;  nor  is  transfusion  per- 
missible at  this  time;  transfusion  is  a  life-saving  proceeding, 
however,  if  the  patient  fails  after  the  tube  is  tied  off  and  the 
source  of  hemorrhage  is  controlled. 

^  Tubal  pregnancy  is  terminated  commonly  in  one  of  two 
ways,  either  by  tubal  rupture  or  tubal  abortion,  tubal  abor- 
tion being  the  more  common.  Tubal  rupture,  however, 
is  common  enough,  and  is  the  source  of  the  most  extensive 
tearing,  hemorrhage  and  collapse.  Frequently  tubal  rupture 
gives  warning  of  its  onset  by  irregular  pains,  by  causing  a 
sense  of  faintness,  and  by  an  associated  slight  hemorrhage  from 
the  uterus.  If  the  patient  has  her  wits  about  her,  and  realizes 
that  something  is  going  wrong,  she  may  call  a  physician  so 
early  that  a  prompt  operation  will  save  collapse,  with  its 
frightful  consequences.  Usually,  however,  the  patient  dis- 
regards these  slight  things,  thinking  them  to  be  merely  the 


154  SURGICAL    PROBLEMS. 

inevitable  symptoms  of  early  pregnancy.  Looked  at  broadly, 
tubal  pregnancy  need  not  to-day  be  regarded  as  the  frightful 
and  almost  fatal  accident  that  we  once  regarded  it.  Often 
It  can  be  diagnosticated  before  rupture,  and  even  after  rup- 
ture our  present  knowledge  of  technique  generally  enables 
us  to  save  the  life  of  the  victim. 


GESTATION.  1 55 

Case  50.  On  the  14th  of  August,  1906,  I  was  called  to 
see  a  young  widow,  thirty  years  of  age,  whose  husband  had 
been  three  years  dead.  Her  physician  told  me  that  she  had 
been  flowing  severely  for  three  days,  and  had  passed  a  fetus, 
which  he  took  to  be  six  weeks  old.  I  curetted  her  and  she 
recovered  promptly  and  soundly. 

Some  six  months  later,  in  January,  1907,  I  was  called  to 
see  her  again,  my  telephone  informant  stating  anxiously  that 
the  patient,  whom  we  will  call  Mrs.  Roberts,  was  in  a  precari- 
ous condition.  I  saw  her  at  eleven  o'clock  in  the  morning. 
She  was  so  weak  and  exhausted  that  she  could  tell  me  little. 
Her  mother,  however,  stated  that  at  half  past  ten  the  night 
before,  while  walking  across  her  bedroom,  Mrs.  Roberts  was 
seized  with  violent  pain  in  the  abdomen;  that  she  screamed 
and  fell  in  a  faint.  Her  physician  arrived  half  an  hour  later, 
and  found  the  patient  on  the  floor,  pulseless.  She  remained 
in  a  semi-conscious  condition  three  hours,  but  under  stimu- 
lants she  slowly  rallied.  With  the  return  of  consciousness 
she  experienced  excessive  pain,  which  lasted  all  night.  At 
the  time  of  my  visit  the  patient  complained  of  great  pain 
in  the  left  chest.  A  careful  examination  was  impossible, 
owing  to  her  exhausted  condition. 

Mrs.  Roberts  looked  very  sick.  She  lay  propped  up  in  bed, 
with  temperature  99.4°  and  a  soft,  easily  compressible  pulse 
of  120.  The  whole  abdomen  was  exquisitely  tender,  but  most 
tender  over  the  sigmoid  region.  I  learned  further  that  for 
several  weeks  past  she  had  had  frequent  painful  flowings, 
coming  on  twice  a  month  and  lasting  ten  days.^  The  patient 
assured  me  that  there  was  no  possibility  of  her  being  pregnant, 
and  in  view  of  my  previous  knowledge  of  her  and  the  great 
gravity  of  her  condition,  which  she  realized,  I  felt  that  her 
statement  must  be  taken  at  its  face  value.  I  felt  also  that 
active  operative  treatment  was  out  of  the  question,  and  ac- 
cordingly ordered  stimulants,  absolute  rest  and  the  infusion 
of  salt  solution  into  the  rectum.  One  result  of  the  infusion 
was  an  abundant  foul  discharge  from  the  rectum  after  a  few 
hours.  The  next  morning  I  saw  Mrs.  Roberts  again.  Her 
condition  was  somewhat  improved,  but  the  abdomen  was  still 
too  tender  for  a  proper  examination.     I  had  her  transferred 


156  SURGICAL   PROBLEMS. 

to  a  hospital,  where  she  continued  to  improve  slowly  through- 
out the  day.  That  night  she  had  a  slight  hemorrhage  from  the 
uterus,  but  it  was  of  no  special  consequence.  On  the  morning 
of  the  third  day  I  found  her  condition  still  critical ;  her  tem- 
perature was  101°,  the  pulse  soft,  irregular,  and  120.  She  in- 
formed me  on  this  day  that  for  the  past  month  she  had  been 
suffering  severely  from  recurring  abdominal  pains,  which, 
associated  with  the  irregular  flowing,  had  greatly  impaired 
her  health.  She  stated  further  that  one  week  previously  she 
had  experienced  a  profound  mental  shock  from  seeing  a  close 
friend  die  in  puerperal  convulsions. 

This  visit  of  mine  was  on  the  31st  of  January.  From 
this  time  on  until  the  17th  of  February,  three  weeks 
from  the  time  of  my  first  visit,  Mrs.  Roberts  improved 
slowly,  the  flow  diminishing,  the  pain  subsiding,  the  tempera- 
ture falling  to  normal,  the  pulse  regaining  good  strength 
and  quality  at  80.^  On  the  17th  of  February  the  pain 
and  tenderness,  which  while  subsiding  had  been  localized  on 
the  left  side,  suddenly  shifted  to  the  right  side,  and  during 
the  night  of  the  17th  the  patient  suffered  again  from 
collapse,  with  excruciating  pain  in  the  right  ovarian  region. 
I  found  her  early  in  the  morning  with  a  pulse  of  no  and  tem- 
perature of  98°.  The  uterus  did  not  feel  enlarged  and  was 
in  fair  position ;  there  was  no  external  hemorrhage.  Although 
the  condition  was  serious,  it  was  not  so  immediately  alarming 
as  I  had  found  it  three  weeks  previously,  and  I  determined, 
after  consultation,  and  careful  explanation  to  the  patient 
and  her  family,  to  proceed  with  a  hasty  emergency  opera- 
tion. 

After  curetting  the  uterus,  I  opened  rapidly  the  abdo- 
men and  found  the  peritoneal  cavity  filled  with  clots  and 
defibrinated  blood.  In  the  right  tube,  about  three  inches 
from  the  uterus,  was  a  mass  the  size  of  an  English  walnut. 
The  right  ovary  was  sclerotic;  the  tube  was  not  ruptured. 
The  left  ovary  and  tube  appeared  in  no  way  abnormal. 
I  removed  the  right  tube  and  ovary,  quickly  washed  out 
the  clots  and  blood  from  the  abdominal  cavity,  re- 
moved a  thickened  and  adherent  appendix  and  closed  the 
abdomen." 


GESTATION.  1 57 

^  One  suspects  at  once  an  extra-uterine  pregnancy,  in  view 
of  the  irregular  flowings,  the  overwhelming  attack  of  pain 
and  the  collapse.  One  must  consider  further  the  possibility 
of  a  twisted  ovarian  cyst. 

-  The  course  of  the  case  up  to  this  point  was  far  from 
characteristic.  One  thinks  of  an  extra-uterine  pregnancy, 
with  a  probable  tubal  abortion,  but  in  addition  to  this  proba- 
bility my  consultants  and  I  were  bearing  in  mind  a  number 
of  other  casualties.  The  pain  and  tenderness  were  mostly 
on  the  left  side,  in  the  sigmoid  region,  which  led  us  to  consider 
the  possibility  of  a  diverticulitis,  or  perhaps  the  impaction 
of  a  calculus  in  the  left  ureter.  It  would  be  unusual  for  a  tubal 
abortion  to  bring  a  patient  into  the  critical  condition  I  have 
described  without  doing  further  damage. 

^  It  is  impossible  for  me  to  explain  the  reason  for  the  left- 
sided  pain  during  the  earlier  weeks  of  this  patient's  illness. 
At  operation  all  the  trouble  was  found  on  the  right  side,  and 
the  blood  which  filled  the  abdominal  cavity  evidently  came 
from  the  fimbriated  end  of  the  right  tube.  The  mass  in  the 
tube,  which  I  supposed,  of  course,  to  be  the  sac  of  an  embryo, 
with  its  contents,  proved  to  be  merely  a  large,  thickened,  lami- 
nated blood-clot,  while  further  examination  of  the  tube  it- 
self revealed  none  of  the  products  of  conception.  It  is  only 
fair  to  say  that  the  tube  was  cut  off  at  a  distance  of  about  an 
inch  from  the  uterus,  and  it  may  well  be  that  there  was  an 
interstitial  pregnancy  —  a  pregnancy  taking  place  in  the  right 
cornu  of  the  uterus  —  and  that  the  hemorrhage  and  pain  were 
due  to  the  expanding  of  the  uterus,  the  blood  escaping  inward 
along  the  course  of  the  tube,  as  well  as  making  its  way  out 
through  the  uterine  canal  and  vagina.  The  need  of  great 
haste  in  the  operation  and  the  critical  condition  of  the  patient 
rendered  careful  examination  impossible,  but  the  fact  re- 
mains that  no  positive  evidence  whatever  of  pregnancy  was 
found.  Be  it  remembered  that  this  patient  had  had  a  mis- 
carriage some  seven  months  before  this  operation. 

Mrs.  Roberts  rallied  slowly  from  the  profound  shock  of  the 
operation,  but  in  the  course  of  two  or  three  days  she  was 
making  good  progress,  and  eventually  recovered  entirely. 
I  have  seen  her  occasionally  during  the  past  three  years. 
There  have  been  no  more  catas trophies,  and  she  has  remained 
well. 


Fig.  3. 

Bismuth-laden  colon,  normal ;  showing  usual  position  of  cecum,  ascending  colon,  the 
two  flexures,  transverse  colon,  descending  colon  and  sigmoid.  Note  splenic  flexure 
somewhat  higher  than  hepatic  flexure.  Note  relations  of  flexures  to  iliac  crests. 
Normal  position  of  colon. 


DIGESTIVE  DISORDERS. 

The  following  thirteen  cases  of  digestive  and  associated 
disorders  form  a  rather  interesting  series,  illustrating  the 
development,  through  a  period  of  six  years,  of  our  enlarged 
conception  of  a  certain  class  of  diseases. 

Case  51.  Mr.  R.  M.  Lunt,  forty-five  years  of  age,  was 
referred  to  me  for  consultation  and  treatment  by  a  Boston 
internist  on  the  9th  of  June,  1905.  The  patient  was  a  broker, 
unmarried,  with  a  fairly  clean  past  history.  He  had  never  been 
the  victim  of  venereal  disease,  or  of  the  eruptive  fevers,  but 
for  many  years  had  suffered  much  constant  abdominal  pain, 
especially  in  the  appendix  region.  This  pain  was  said  to  be 
aggravated  by  all  forms  of  food,  so  that  the  patient  was 
obliged  to  diet  carefully,  and  at  the  time  of  his  consulting  me 
was  subsisting  mainly  on  milk,  shredded  wheat,  oysters,  eggs 
and  cooked  fruits.  He  was  easily  exhausted  by  slight  exertion, 
and  was  in  an  extremely  depressed  nervous  state.  He  com- 
plained of  frequent  flatulence  and  rumblings  in  the  bowels, 
of  irregular  attacks  of  abdominal  pain,  increased  sometimes 
by  food,  sometimes  by  exertion.  He  had  consulted  many 
physicians,  and  had  been  through  a  great  variety  of  treatment, 
especially  in  the  way  of  stomach  washings  and  the  use  of 
antacids,  all  with  no  permanent  benefit.  He  was  the  victim 
of  an  obstinate  and  distressing  constipation  also,  and  was 
obliged  to  secure  a  movement  of  the  bowels  by  large  doses 
of  aperient  waters.  The  nature  of  his  movements  is  worthy 
of  note.  A  competent  chemist  reported  as  follows:  "  The 
movements  are  made  up  of  various  hard,  firm  masses,  inter- 
mixed with  an  enormous  amount  of  mucin.  They  are  of 
slightly  acid  reaction.  Large  fragments  of  prunes  could 
be  seen.  Under  the  microscope  there  were  found  numerous 
fatty  acid  crystals,  some  soap  and  a  great  many  muscle  fibers, 
a  few  starch  granules,  fragments  of  mucin,  some  stained  and 
some   unstained   with   hydrobilirubin,    epithelial   cells,    both 

159 


I60  SURGICAL    PROBLEMS. 

stained  and  unstained,  and  numerous  nuclei  of  epithelial 
cells  which  had  been  digested,  together  with  a  large  number 
of  hematoidin  crystals.  This  condition  shows  very  clearly 
that  there  is  a  severe  catarrhal  enteritis,  of  a  chronic  character, 
associated  with  a  colitis  which,  according  to  the  presence  of 
the  fecal  masses,  can  only  be  accounted  for  by  the  fact  that 
there  is  a  good  deal  of  spasm  of  the  intestinal  coats;  and  the 
presence  of  the  hematoidin  crystals  indicates  the  presence 
of  blood  in  the  feces,  from  a  hemorrhage  occurring,  probably, 
sometime  before  the  feces  were  passed."^ 

My  consultant  had  made  a  careful  study  of  Mr.  Lunt,  and 
had  convinced  himself  that  the  patient's  disorder  was  confined 
to  the  large  intestine  mainly ;  that  the  colon  was  acting  irregu- 
larly and  ineffectively,  and  that  probably  there  was  an  asso- 
ciated chronic  appendicitis,  which  might  well  be  the  initial 
cause  of  his  ailment.  I  was  asked,  accordingly,  to  make  my 
own  study  of  the  case,  and  to  perform  an  exploratory  operation 
if  that  should  seem  best. 

My  physical  examination  of  Mr.  Lunt  was  far  from  con- 
clusive. The  man  was  of  a  familiar  type, —  anxious  looking, 
well  developed,  but  emaciated,  with  furred  tongue  and  tremu- 
lous hands.  He  described  himself  as  utterly  unfitted  for  work, 
although  his  work  was  not  particularly  exacting.  In  addition 
to  the  symptoms  already  described,  he  complained  of  blurring 
of  vision,  shortness  of  breath  and  inability  to  concentrate 
mentally.  I  found  his  chest  to  be  not  abnormal  and  the  eyes 
to  be  sound.  The  abdomen  was  slightly  distended,  especially 
below  the  navel.,  when  he  stood ;  there  was  a  marked  pulsation 
of  the  aorta  in  the  epigastrium;  the  skin  was  somewhat  dry 
and  scaly  and  was  tender  over  the  whole  abdomen;  there 
was  marked  tenderness  at  McBurney's  point;  the  examining 
finger  entered  the  rectum  with  difficulty ;  there  was  slight  pro- 
lapse of  the  right  kidney.  I  made  no  special  investigation  of 
the  position  of  the  stomach,  though  by  percussion  and  in  view 
of  the  general  contour  of  the  abdomen  I  concluded  that  the 
stomach  was  somewhat  prolapsed. 

An  exploration  seemed  reasonable;  accordingly,  on  the  15th 
of  the  same  month  I  opened  the  abdomen  in  the  median  line. 
The  appendix  was  partially  obliterated  and  buried  In  adhesions. 


DIGESTIVE   DISORDERS.  l6l 

I  removed  it.  The  transverse  colon  presented  an  appearance 
unusual  to  me  at  that  time.  My  notes  describe  it  as  shrunken 
and  thickened,  the  lumen  scarcely  admitting  the  little  finger; 
the  stomach  was  enlarged  with  its  greater  curvature  four  inches 
below  the  navel,  as  the  patient  lay  on  the  operating  table; 
the  shrunken  transverse  colon  lay  at  the  pubes;  the  cecum 
was  deeply  injected  and  greatly  dilated;  the  sigmoid  was 
normal  in  appearance,  but  both  sigmoid  and  cecum  were 
extremely  movable,  and  hung  from  long  mesenteries.^ 

^  The  condition  here  described  has  long  been  known  as 
mucous  colitis,  and  has  been  regarded  as  a  nervous  disorder 
akin  to  that  hypothetical  disease,  nervous  dyspepsia.  Most 
of  the  text-books  describe  mucous  colitis  as  being  a  disease 
peculiar  to  nervous  women  and  to  young  boys.  They  recite 
a  great  variety  of  symptoms,  both  nervous  and  digestive; 
they  tell  of  emaciation,  irregular  appetite,  distress  after  food, 
headache,  constipation,  alternating  with  diarrhea,  and  the 
discharge  of  varying  amounts  of  mucus  from  the  bowel,  with 
sometimes  actual  casts  of  the  bowel  itself. 

^  These  findings  cause  no  special  interest  to-day,  but  six 
years  ago  we  were  less  familiar  with  the  nature  and  character- 
istics of  visceral  ptosis.  That  the  whole  colon  was  prolapsed, 
owing  to  an  abnormally  long  mesentery,  is  obvious,  and  the 
prolapse  of  the  hepatic  flexure,  associated  with  a  kink  and 
partial  obstruction  at  the  high,  normally  placed  splenic 
flexure,  was  undoubtedly  the  cause  of  the  apparently  small 
size  of  the  transverse  colon  and  of  its  lack  of  proper  function. 

This  condition  of  the  intestine  seemed  to  me  capable  of 
being  remedied  by  various  measures,  such  as  fastening  the 
colon  high  into  place,  performing  colostomy,  followed  by 
through-and-through  washings,  or  even  by  a  resection  of 
part  of  the  colon;  but  in  view  of  the  feebleness  of  the  man 
I  thought  best  to  do  the  rapid  and  simple  operation  of 
anastomosing  the  movable  cecum  to  the  movable  sigmoid. 
I  performed  that  operation,  accordingly,  thereby  sidetrack- 
ing practically  the  whole  of  the  large  intestine. 

The  patient  bore  the  operation  very  well,  his  pulse  that 
evening  being  72  and  his  temperature  normal.  He  made 
excellent  progress  throughout  his  convalescence.  The  effect 
of  the  operation  was  practically  to  cure  his  constipation  and 


l62  SURGICAL    PROBLEMS. 

to  relieve  him  of  his  flatulence.  At  the  end  of  two  weeks  he 
went  home,  in  much  improved  spirits.  I  have  followed  his 
subsequent  condition  with  a  great  deal  of  interest,  and  hear 
from  him  still  two  or  three  times  a  year.  His  nervous  symp- 
toms have  improved ;  he  is  able  to  attend  to  his  business  with 
vigor  and  reasonable  regularity;  his  eyesight  is  good;  he  can 
eat  and  digest  an  average  diet,  and  has  little  pain,  while  his 
mucous  colitis  has  gradually  improved  until  now  it  troubles 
him  not  at  all.  On  the  whole,  I  feel  we  are  justified  in  conclud- 
ing that  the  results  of  the  operation  have  been  satisfactory. 


DIGESTIVE   DISORDERS.  163 

Case  52.  For  some  seventeen  years,  up  to  the  summer  of 
1907,  I  employed  frequently  as  a  professional  nurse  Miss 
Margaret  O' Neil,  a  rugged,  vigorous,  hard-headed,  able  Scotch 
woman,  of  the  type  on  whom  a  surgeon  counts  for  accurate 
information  and  reliable  service.  Twice  during  the  years 
1903  to  1906  she  went  to  Cuba  in  her  professional  capacity, 
and  was  under  severe  strain  during  those  visits.  Miss  O'Neil 
was  fifty  when  she  consulted  me  professionally  by  letter, 
in  July,  1907.  At  that  time  she  was  suffering  severely  from 
an  acute  arthritis  of  both  knees,  and  informed  me  that  for 
more  than  twenty  years  she  had  been  subject  to  periodic  at- 
tacks of  arthritis,  which  impaired  her  activities  and  wore  upon 
her  strength  and  spirits.  Aside  from  this  disturbance  she 
had  suffered  all  her  life  from  some  indefinite  form  of  dyspepsia; 
from  constipation,  alternating  with  diarrhea;  from  irregular, 
nagging,  general  abdominal  pains,  especially  pain  in  the  left 
upper  quadrant  of  the  abdomen;  from  excessive  flatulence; 
and  occasionally  from  pain  in  the  region  of  the  appendix.  Dur- 
ing the  last  three  years  she  had  found  herself  less  able  to  do 
her  work,  on  account  of  increasing  dyspnea,  which  was  asso- 
ciated with  impaired  vision  and  some  degree  of  emaciation. 
For  the  past  three  weeks  she  had  been  extremely  rheumatic 
as  she  said,  and  had  been  able  to  walk  with  the  greatest  diffi- 
culty, spending  much  of  her  time  in  bed.  Most  of  this  infor- 
mation was  conveyed  to  me  by  correspondence. 

On  the  15th  of  July  I  sent  for  her  to  enter  a  hospital  in  my 
neighborhood.  I  found  her  much  changed  since  my  last 
interview  with  her  six  months  before.  She  was  a  large-framed, 
rather  gaunt  woman,  now  emaciated  and  anxious  looking.  She 
was  evidently  in  pain,  and  complained  of  the  continual  stiff- 
ness and  pain  in  her  knee  joints.  There  was  a  marked  mitral 
insufficiency  also  and  some  hypertrophy  of  the  heart.  The 
mitral  leak  was  apparently  well  compensated.  She  told  me 
that  for  two  weeks  she  had  been  running  a  fever  of  from  ioi° 
to  102°,  with  increasing  pain  in  the  right  side  of  the  abdomen 
and  chest.  I  found  her  temperature  to  be  102°,  her  pulse 
100,  leukocyte  count  8,000.  There  was  obscure  pain  and  ten- 
derness, with  a  small,  indefinite  mass  to  be  felt  in  both  iliac 
regions ;  the  right  side  of  the  chest  was  full  of  fluid ;  the  heart 


164  SURGICAL    PROBLEMS. 

was  crowded  somewhat  to  the  left  by  this  fluid ;  the  spleen 
and  liver  were  not  enlarged. 

Here,  then,  was  a  woman  acutely  ill,  apparently,  with  a 
pleurisy  and  possibly  an  appendicitis,  superimposed  upon 
her  chronic  arthritis.  The  mass  in  the  left  side  of  the  pelvis 
could  not  be  well  made  out,  but  seemed  to  me  to  be  a  small 
ovarian  cyst.  It  was  quite  obvious  that  the  first  thing  to  do 
was  to  bring  her  through  the  acute  crisis.  In  the  course  of 
a  week  she  was  greatly  better ;  the  right  chest  had  cleared  up, 
the  heart  had  come  into  good  position  and  was  acting  well, 
the  temperature  was  running  practically  normal,  but  there  was 
more  pain  and  irritation  in  the  region  of  her  appendix  than  at 
the  time  of  her  entering  the  hospital ;  the  abdomen  was  some- 
what distended  constantly  and  was  everywhere  rather  tender, 
especially  in  the  region  of  the  spleen  and  in  the  right  lower 
quadrant.^ 

In  view  of  Miss  O' Neil's  improved  condition  and  the  prob- 
ability that  the  underlying  trouble  lay  within  the  abdomen, 
I  decided  to  operate,  and  to  remove  the  appendix,  if  nothing 
more.  Accordingly,  on  the  23d  of  July,  I  opened  the  abdomen, 
and  was  immediately  struck  by  an  unlooked-for  condition 
there.  This  was  a  marked  ptosis  of  the  stomach  and  large 
intestine, —  the  ascending  colon  and  the  transverse  colon 
being  almost  entirely  within  the  pelvis,  the  stomach  being 
completely  below  the  navel,  and  the  splenic  flexure  so 
sharp  as  to  produce  an  apparent  obstruction.  The  uterus 
and  ovaries  were  small,  the  pelvic  organs  were  not  diseased 
and  were  quite  movable.  The  appendix  was  in  a  state  of  sub- 
acute inflammation,  was  five  inches  long  and  was  obstructed 
one  inch  from  its  tip.  There  was  nothing  peculiar  to  be  felt 
or  seen  in  the  region  of  the  liver  or  bile-passages.  It  did  not 
seem  best  to  me  at  that  time  to  do  more  than  remove  the  ap- 
pendix, and  to  provide  by  subsequent  treatment  for  the  ptosis.^ 

Miss  O'Neil  made  a  tedious  recovery  from  the  operation. 
The  removal  of  the  appendix  relieved  her  immediate  distress, 
but  the  marked  ptosis  remained.  In  1907  I  had  not  as  yet 
come  to  any  positive  conviction  regarding  the  treatment 
of  ptosis.  In  this  case,  however,  I  employed,  as  I  was  accus- 
tomed  to  employ   at   that   time,   a  well-fitting   corset-belt, 


DIGESTIVE   DISORDERS.  165 

which  greatly  relieved  many  of  the  symptoms  and  seemed 
in  a  fashion,  to  benefit  the  chronic  arthritis.  Miss  O'Neil 
returned  home  with  fresh  courage,  expecting  to  take  up  her 
work  later  in  the  year.  Unfortunately,  her  endocarditis 
progressed  rapidly,  and  we  learned  in  the  course  of  six  months 
that  she  had  succumbed  to  heart  disease.^ 

^  At  that  time  I  was  unable  to  make  up  my  mind  whether 
the  acute  pleurisy  was  coincident  with  or  was  the  effect  of 
some  other  ailment.  It  seemed  probable,  however,  that  the 
infection  which  was  causing  the  arthritis  caused  the  pleurisy 
also,  and  not  improbably  was  behind  the  abdominal  inflamma- 
tion. The  source  of  this  infection  was  far  from  apparent. 
I  suspected  the  throat,  for  in  those  days  we  were  looking 
first  to  the  tonsils  as  a  source  of  arthritic  inflammation. 
Miss  O'Neil's  throat  was  certainly  affected,  though  not 
markedly;  she  had  a  mild  tonsillitis,  which  gave  her  little 
or  no  trouble. 

-  The  marked  ptosis  which  I  have  described  is  a  common 
cause  of  indefinite  chronic  dyspepsia.  The  dragging  of  the 
prolapsed  viscera  upon  the  mesentery  and  blood  supply 
interferes  constantly  with  the  proper  nutrition  of  the  organs; 
the  innervation  is  disturbed,  the  chemical  activities  of  the 
glands  are  interfered  with,  while  the  partial  obstruction  at 
the  splenic  flexure  is  a  continual  source  of  pain,  irregularity 
of  the  bowels  and  distention  with  gas.  In  these  cases,  one 
sees  characteristic  discharges  of  small,  hard,  fecal  masses  from 
the  bowel,  occasionally  interrupted  by  attacks  of  diarrhea. 
There  is  blocking  of  the  fecal  stream  in  the  caput,  which 
is  consequently  a  common  seat  of  fecal  impaction. 

^  In  view  of  our  present  studies,  it  is  not  unreasonable  to 
assert  that  the  circle  of  disorders  which  led  up  to  Miss  O'Neil's 
death  was  this:  (i)  A  pronounced  gastro-enteroptosis,  con- 
genital; (2)  a  resulting  chronic  intestinal  fermentation, 
leading  to  the  formation  of  toxins ;  (3)  a  low  grade  of  chronic 
toxemia,  afifecting  constantly  the  serous  surfaces,  especially 
the  joints;  (4)  an  acute  pleuritis,  secondary  to  the  chronic 
arthritis  and  the  intestinal  toxemia;  (5)  an  endocarditis, 
dependent  upon,  and  associated  with,  the  toxemia. 


1 66  SURGICAL   PROBLEMS. 

Case  53.  Another  case  of  chronic  dyspepsia,  associated 
with  baffling  symptoms,  was  that  of  Ada  Blowitz,  an  over- 
worked young  Jewish  woman,  unmarried,  twenty-six  years 
old,  who  consulted  me  on  the  20th  of  February,  1908.  She 
was  a  mill  operative,  and  told  me  that  she  was  worn  out 
with  nursing  an  invalid  mother. 

She  described  a  dietary  such  as  would  shock  any  self- 
respecting  canine.  She  said  that  for  years  she  had  been  sub- 
ject to  chronic  toothache,  which  disturbed  her  sleep  and  made 
her  constantly  wretched.  Nine  months  before  I  saw  her  she 
began  to  be  troubled  with  pains  in  the  legs  and  back,  with 
headache,  with  occasional  general  abdominal  pains,  not 
specially  dependent  on  food  and  not  localized ;  she  had  a  dis- 
tressing dysmenorrhea,  which  caused  her  great  suffering, 
with  constipation,  poor  appetite,  sour  mouth,  acid  stomach, 
and  occasional  nausea  and  vomiting,  without  relation  to  food. 
She  had  grown  thin  and  feeble,  especially  in  the  past  six 
months.^ 

I  found  this  patient  to  be  all  that  she  described  herself. 
She  was  an  anxious-looking  girl,  fairly  well  developed,  but 
under-nourished;  her  teeth  were  in  bad  condition,  carious 
and  nearly  useless;  her  chest  was  not  peculiar  and  her  heart 
was  sound.  The  abdomen,  however,  showed  fairly  character- 
istic appearances.  When  she  stood,  her  attitude  was  extremely 
faulty,  round  shouldered,  with  projecting  scapulae  and  flat- 
tened dorsal  spine.  The  abdomen  was  retracted  in  its  upper 
portion,  but  bulged  below  the  navel;  the  aortic  pulsation 
above  the  navel  was  marked.  Her  uterus  was  retroverted, 
and  on  examining  the  rectum  I  found  the  finger  entered  a  tight 
sphincter  and  encountered  a  choked  rectal  ampulla.  These  evi- 
dences alone  are  sufficient  to  suggest  a  general  descent  of  the 
abdominal  viscera,  undoubtedly  congenital.^  The  abdominal 
contour  was  long  and  narrow,  and  the  lower  ribs  approached 
nearly  to  the  spine  of  the  ilia.  On  further  investigation,  I 
discovered  the  right  kidney  to  be  down  and  extremely  movable, 
while  the  stomach  was  prolapsed,  as  shown  by  air  distention, 
and  the  whole  lower  portion  of  the  abdomen  was  tympanitic ; 
the  skin  over  the  abdomen,  moreover,  was  dry  and  tender 
at  numerous  points  not  especially  significant. 


DIGESTIVE   DISORDERS.  1 67 

I  believe  most  practitioners  would  have  agreed  with  me 
at  the  time  of  this  examination,  in  regarding  the  girl  as  being 
in  a  state  of  advanced  "  physical  and  nervous  prostration," 
due  to  her  conditions  of  living.  The  visceral  ptosis,  however, 
was  doubtless  an  element  in  the  situation,  though  I  did  not 
realize  that  it  might  be  the  important  underlying  factor. 
I  treated  the  ptosis  then  as  most  of  us  were  treating  such 
cases,  as  an  incident  in  the  condition.  I  was  able  to  secure 
for  the  girl  the  services  of  a  dentist,  a  month's  rest  in  pleasant, 
hygienic  surroundings,  and  saw  that  she  got  proper  food  and 
tonics.  I  treated  the  ptosis  by  a  well-fitting  corset-belt, 
which  immediately  relieved  greatly  her  uncomfortable  diges- 
tive symptoms  and  her  abdominal  pains. 

This  girl  disappeared  from  view  shortly  after  her  visit 
to  me,  but  a  year  later  she  reported  that  she  had  gone  back 
to  work  in  greatly  improved  condition,  and  that  she  con- 
tinued with  advantage  to  wear  the  corset-belt. 

^  The  train  of  symptoms  described  by  this  patient  is  such 
as  is  frequently  ascribed  to  being  "  run  down  "  from  overwork, 
bad  hygiene  and  absence  of  the  pleasant  things  of  life,  and  such 
accounting  for  the  symptoms  is  entirely  reasonable.  One 
thinks  also  of  the  special  causes  for  digestive  disturbance: 
bad  teeth,  leading  to  improper  mastication  and  consequent 
gastro-intestinal  irritation;  gastric  ulcer,  which  is  common 
enough  in  under-nourished  young  women;  and  not  improb- 
ably some  occult  form  of  tuberculosis. 

^Descent  of  the  stomach,  and  even  of  the  intestines,  has 
long  been  recognized  by  surgeons,  for  the  abdominal  operator 
is  accustomed  to  find  a  stomach  at  the  navel  and  a  corre- 
spondingly low  position  of  the  colon.  The  general  practi- 
tioner, however,  and  even  the  surgeon,  interested  in  abdomi- 
nal diseaise,  has  been  little  accustomed  to  locate  and  map  out 
accurately  the  actual  condition  and  position  of  prolapsed 
intestines.  In  the  case  under  discussion  I  thought  little  of 
the  descent  of  the  colon,  but  regarded  the  low-lying  stomach 
as  of  much  the  greater  importance,  a  view  which  I  am  now 
convinced  is  erroneous. 


1 68  SURGICAL    PROBLEMS. 

Case  54.  The  following  brief  study  illustrates  a  familiar 
condition  which  used  to  baffle  practitioners.  The  condition 
to-day  is  not  always  understood,  and  is  still  frequently  treated 
with  drugs,  diet  and  massage. 

Mrs.  Wall,  at  the  age  of  fifty-one,  was  sent  to  me  by  a  com- 
petent gynecologist,  in  the  summer  of  1908.  My  consultant 
wrote  that  he  had  removed  a  small,  benign  growth  from  her 
cervix  six  months  before ;  that  this  operation  had  been  followed 
by  a  month  of  extreme  prostration,  and  that  the  patient  was 
not  yet  entirely  recovered. 

Mrs.  Wall  told  me  that  she  had  been  a  "  dyspeptic  " 
all  her  life.  She  had  two  children,  who  were  now  grown. 
She  complained  of  continual  chronic  constipation,  frequent 
gnawing  pains  low  in  the  epigastrium  and  not  influenced  by 
food,  and  a  slight  constant  nausea;  she  said  she  was  rapidly 
running  down,  that  the  pains  were  becoming  more  severe, 
and  that  sleep  had  become  almost  impossible  for  her.  I  could 
make  nothing  else  out  of  her  history. ^ 

^  The  story  up  to  this  point  is  not  unfamiliar,  and  is  told 
often  to  gynecologists.  Not  long  ago  we  used  to  think  that 
this  train  of  symptoms  was  due  to  pelvic  disorders  alone, — 
to  displacements  of  the  uterus,  to  old  inflammations  of  the 
tubes  and  ovaries  or  even  to  tears  of  the  cervix.  These  were 
called  reflex  symptoms.  All  of  us,  neurologists,  internists, 
surgeons,  talked  about  reflex  symptoms,  without  knowing 
exactly  what  we  meant. 

I  found  Mrs.  Wall  to  be  a  large,  stout,  cheerful,  rather 
"  nervous  looking  "  woman.  She  appeared  to  be  nearer  sixty- 
five  than  fifty-one  years  of  age.  The  pelvic  organs  were  not 
peculiar  and  the  perineum  was  sound;  her  skin  and  muscles 
were  lax  and  flabby;  the  abdomen  was  large  and  very  much 
relaxed;  it  seemed  to  be  everywhere  tympanitic,  but  on 
careful  distention  of  the  stomach  with  air  I  demonstrated 
the  lesser  curvature  of  that  organ  to  be  about  four  inches 
below  the  navel;  I  could  feel  both  kidneys  movable  and  in 
descent;  the  colon  also  was  obviously  prolapsed.  There  was 
no  evidence  anywhere  of  a  tumor,  or  other  serious  organic 
derangement.    At  that  time  it  seemed  to  me  needless  to  carry 


DIGESTIVE    DISORDERS.  1 69 

the  investigation  further;  it  was  clear  that  much  of  Mrs. 
Wall's  discomfort  was  due  to  her  visceral  ptosis.  Accordingly 
I  had  made  for  her  a  well-fitting  corset-belt  which  she  was 
to  wear  constantly  when  on  her  feet. 

Six  months  later  she  sent  me  word  that  she  was  much 
improved,  and  that  she  expected  always  to  wear  the  belt, 
as  it  gave  her  great  comfort. 

This  easily  investigated  and  familiar  type  of  ptosis  is  prob- 
ably congenital,  but  such  ptosis  is  increased  by  child-bearing, 
by  advancing  age  and  by  laxity  of  the  normal  supporting 
structures.  The  exact  extent  of  the  ptosis  was  not  demon- 
strated by  the  crude  examination  I  made  at  that  time. 
Enough  was  apparent,  however,  to  encourage  me  in  the  belief 
that  the  conventional  corset-belt  which  I  ordered  would 
relieve  the  patient  of  her  symptoms. 


lyO  SURGICAL    PROBLEMS. 

Case  55.  Mrs.  John  Sullivan  told  me  that  she  was  the 
victim  of  many  pregnancies,  when  I  went  to  see  her  at  her 
own  house,  with  a  consultant,  in  the  neighboring  town  of 
Sylvan,  on  the  29th  of  December,  1908.  She  seemed  to  be  a 
very  sick  woman,  and  gave  me  much  anxiety;  indeed,  her 
physician  had  told  her  husband  the  night  before  my  visit 
that  she  could  scarcely  live  through  twenty-four  hours. 
She  was  thirty-five  years  old,  and  had  borne  ten  children, 
the  last  confinement  being  four  years  before  I  saw  her.  Aside 
from  her  puerperal  history,  there  was  nothing  to  cause  com- 
ment. She  came  of  strong,  vigorous  people,  of  Irish  stock, 
and  had  always  been  well  as  a  girl  and  young  woman.  After 
her  first  two  children  were  born  she  began  a  course  of  gyne- 
cological sufferings  such  as  are  common  enough, —  backache, 
leucorrhea,  frequency  and  incontinence  of  urine,  constipation 
and  occasional  dyspepsia.  She  told  me  that  since  her  last 
confinement  she  had  had  much  abdominal  pain,  especially 
in  the  region  of  the  appendix,  though  the  pain  often  located 
itself  in  the  left  groin,  and  even  in  the  splenic  region.  These 
pains,  she  said,  were  associated  with  much  rumbling  of  the 
bowels  and  with  flatulence,  and  were  relieved  by  the  passage 
of  gas  and  by  movements  of  the  bowels.  She  stated  that 
her  movements  had  been  growing  peculiar.  From  her  de- 
scription, they  seemed  to  be  like  those  of  the  herbivora, — 
small,  hard  balls. 

My  consultant  was  perfectly  definite  in  his  judgment  of 
her  condition,  and  was,  in  the  main,  entirely  correct.  He 
told  me  that  she  had  a  right  floating  kidney  and  was  in  the 
midst  of  a  Dietl's  crisis.  It  appeared  that  for  the  last  four 
days  she  had  had  increasingly  severe  abdominal  pain,  with 
exquisite  tenderness  on  the  right  side  of  the  abdomen  and 
a  rising  temperature.  The  urine  was  "  scanty,  heavy,  scald- 
ing in  the  passage";  it  contained  one  quarter  percent  of 
albumen  and  numerous  hyaline  and  granular  casts. ^ 

I  found  Mrs.  Sullivan  to  be  a  large,  vigorous-looking  woman, 
extremely  flushed  and  anxious.  Her  abdomen  was  slightly 
distended  and  everywhere  tympanitic;  it  was  everywhere 
tender  also,  but  exquisitely  tender  especially  in  the  right 
inguinal  and  right  umbilical  regions.     One  could  make  out 


Fig.  4.     Case  56. 

Stomach  filled  with  bismuth  paste.     Some  sagging  at  pyloric  end  but  position  not  far 
from  the  normal.     Patient  standing. 


DIGESTIVE    DISORDERS.  I7I 

readily  an  indefinite  mass,  the  size  of  a  man's  fist,  in  the  right 
renal  region, —  a  mass  which  descended  somewhat  below  the 
crest  of  the  ilium  and  could  be  returned  upward  by  manipu- 
lation; indeed,  .  the  result  of  manipulation  and  replace- 
ment of  this  mass,  presumably  the  kidney,  greatly  relieved 
the  patient.  The  woman's  bowels  had  been  opened  by  cathar- 
sis; there  was  no  vomiting.  One  notable  feature  of  the  case, 
however,  was  a  slight,  marked  jaundice,  which  was  said 
to  have  existed  for  some  three  days  and  to  have  appeared 
at  irregular  previous  intervals.  The  liver  was  slightly  enlarged 
and  there  was  some  tenderness  in  the  region  of  the  gall  bladder, 
though  nothing  in  the  history  pointed  definitely  to  a  cholan- 
gitis or  attacks  of  gallstone  colic. ^ 


^  The  train  of  symptoms  described  might  well  and  properly 
lead  one  to  the  diagnosis  of  floating  kidney.  We  find  all  the 
text-books  stating  that  a  floating  kidney  is  a  frequent  cause 
of  dyspeptic  symptoms  and  of  abdominal  pains,  and  we  are 
told  commonly  that  the  replacement  of  the  kidney  will  re- 
lieve the  discomfort.  In  a  sense,  such  a  statement  is  true, 
but  we  have  come  to  look  for  a  more  far-reaching  cause  and 
a  more  complex  condition  of  disorders  than  is  explained  by 
the  mere  term,  floating  kidney.  We  now  know  that  floating 
kidney,  which  is  almost  always  on  the  right,  is  associated 
frequently  with  descent  of  the  ascending  colon,  and  that  the 
falling  colon  brings  with  it  the  transverse  colon  and  the  stom- 
ach, while  it  drags  upon  the  liver  and  bile  passages.  In  great 
numbers  of  cases  we  must  believe  that  the  primary  condi- 
tion is  a  descent  of  the  colon,  and  that  the  descent  of  the  kid- 
ney, like  the  descent  of  the  transverse  colon  and  stomach, 
is  often  secondary. 

^  This  jaundice  is  commonly  associated  with  a  markedly 
movable  kidney  and  with  Dietl's  crises,  as  all  the  text-books 
confess.  The  true  significance  of  the  condition,  however, 
is  infrequently  mentioned.  It  is  not  that  a  descending  kid- 
ney necessarily  and  as  an  Isolated  organ  drags  upon  the  duo- 
denum and  bile  passages,  thus  causing  obstruction,  but  it 
would  appear  that  the  descent  of  the  colon  Is  primary,  and 
that  the  weight  of  the  colon,  frequently  loaded,  drags  upon 
the  kidney,  the  stomach,  the  duodenum  and  the  bile  pas- 
sages. Certain  it  is  that  we  find  enteroptosis  associated  with 
floating  kidney,  and  occasionally  associated  with  symptoms 
of  bile-passage  disease,  notably  with  jaundice. 


172  SURGICAL    PROBLEMS. 

Although  these  various  facts  were  clear,  nevertheless  I 
fell  into  the  common  error  of  regarding  the  descent  of  the 
kidney  as  the  one  significant  feature  in  the  case,  and  paid 
little  regard  to  the  obvious  ptosis  of  other  organs.  I  advised 
palliative  treatment  for  the  present,  replacing  the  kidney 
and  keeping  the  woman  flat  in  bed  until  her  acute  symptoms 
had  subsided.  In  the  course  of  a  month  she  felt  well,  but  was 
easily  persuaded  to  submit  to  an  operation  for  fixation  of  the 
errant  kidney. 

On  the  15th  of  February  I  exposed  the  kidney,  which 
was  found  to  be  extremely  movable,  and  fixed  it  by  the  cap- 
sule-splitting method  of  Edebohls.  Mrs.  Sullivan  made  a  slow 
convalescence,  but  at  the  end  of  a  month  was  well  and  entirely 
free  from  the  pain  following  the  operation.  In  the  course  of 
the  next  year  she  went  about  her  usual  occupations  with  re- 
newed vigor,  but  still  she  was  far  from  being  free  from  many 
of  her  digestive  symptoms.  A  year  later,  early  in  1910, 
I  advised  her  physician  to  have  made  for  her  a  corset-belt. 
She  has  been  wearing  this,  I  am  told,  for  many  months  now, 
and  finds  that  it  gives  her  great  comfort  and  relieves  her  from 
most  of  her  distressing  symptoms,  though  the  actual  condi- 
tion of  the  viscera,  and  the  extent  of  their  prolapse,  is  even 
now  unknown  to  me. 


DIGESTIVE   DISORDERS.  1 73 

Case  56.  The  case  of  Mrs.  Wheeler  was  long,  intricate, 
difficult  and  informing.  I  was  summoned  to  see  her  in  con- 
sultation at  a  country  house  in  northern  New  York,  on  the 
3d  of  August,  1909.  It  seemed  undoubted  at  that  time  that 
the  circumstances  of  her  past  life  had  an  important  bearing  on 
her  serious  illness.  She  was  thirty-four  years  old,  and  had 
been  a  widow  four  years.  During  her  girlhood  and  short  mar- 
ried life  she  had  lived  in  extremely  moderate  circumstances, 
had  herself  borne  the  brunt  of  much  family  hardship,  and 
after  her  marriage  had  nursed  an  invalid  husband  through 
a  fatal  phthisis.  She  had  always  been  a  person  of  retiring 
disposition  and  somewhat  morbid  habit,  and  after  her  hus- 
band's death,  finding  herself  in  a  state  of  comparative  pov- 
erty, she  had  fallen  into  a  condition  of  mental  and  physical 
collapse,  from  which  she  had  not  recovered.  Fortunately, 
perhaps,  for  her,  about  a  year  before  I  saw  her,  a  friend, 
a  wealthy  young  woman,  had  taken  her  into  her  household 
as  companion  and  intimate.  During  the  past  year,  however, 
her  nervous  and  physical  troubles  had  increased.  She  was 
subject  to  long  periods  of  depression,  to  headache,  to  ab- 
dominal pains, —  cramplike  in  character,  located  generally 
in  the  epigastrium, —  to  constipation,  to  nausea,  to  a  sense 
of  being  utterly  exhausted,  so  that  for  days  together  she 
lay  in  bed  hardly  able  to  raise  her  head.  Thinking  her  dis- 
order was  altogether  mental,  she  applied  to  practitioners  of 
the  Emmanuel  Movement,  but  was  informed  that  she  should 
consult  a  physician.  Finally,  in  March,  convinced  that  she 
was  the  victim  of  some  serious  organic  derangement,  she 
consulted  her  family  physician,  who  sent  her  to  a  hospital 
and  put  her  under  the  care  of  a  specialist  in  gastric  disease. 
She  remained  in  the  hospital  for  a  month.  During  that 
period  she  was  carefully  examined  and  given  all  the  conven- 
tional tests.  The  physician  under  whose  care  she  was  tells 
me  that  he  thought  at  one  time  she  had  gastric  ulcer;  indeed, 
he  was  convinced  that  that  was  the  fact,  but  as  she  improved 
somewhat,  with  rest  in  bed  and  careful  dieting,  he  was  satis- 
fied to  send  her  home  finally  as  a  probably  cured  case  of  gas- 
tric ulcer.  She  then  went  to  the  country,  where  she  had  been 
for  gome  two  months  when  I  was  summoned  to  her.     The 


174  SURGICAL    PROBLEMS. 

local  physician  who  called  me  said  that  she  probably  had 
gallstones.  It  appeared  that  her  condition  of  general  pros- 
tration had  not  improved  during  her  residence  in  the  country. 
She  was  scarcely  able  to  stand,  and  was  carried  about  in  a 
wheel-chair  or  in  an  easy  carriage,  but  found  that  the  slight- 
est exertion  or  jar  brought  on  attacks  of  severe  epigastric 
pain.  Her  diet  was  limited;  she  was  in  terror  of  all  food, 
was  becoming  greatly  emaciated  and  was  extremely  despond- 
ent. I  was  told  that  she  was  never  free  from  a  sense  of  dis- 
tress in  the  epigastrium,  and  that  this  distress  was  punc- 
tuated every  week  or  two  by  attacks  of  severe  epigastric 
pain,  which  was  relieved  by  morphia  only. 

I  found  Mrs.  Wheeler  to  be  a  gentle,  fragile-looking  woman, 
with  fair  color,  but  in  the  flabby  and  nerveless  condition 
common  to  persons  who  have  lain  for  many  weeks  in  bed. 
She  was  fairly  well  developed  and  not  ill  nourished.  She  was 
intelligent  and  took  a  keen  interest  in  almost  all  matters 
of  conversation.  Her  tongue  was  slightly  coated,  her  chest 
negative,  her  pulse  70,  her  temperature  normal.  The  whole 
abdomen  was  slightly  distended  and  excessively  tender  every- 
where, more  especially  in  the  epigastrium  and  the  region 
of  the  gall  bladder.  She  bore  palpation  with  great  distress. 
The  slight  abdominal  distention  was  general ;  the  right  kid- 
ney was  palpable,  but  not  prolapsed  apparently.  I  saw  her 
twice  in  the  course  of  a  week.  During  that  period  her  symp- 
toms did  not  improve,  and  the  recurring  attacks  of  pain  seemed 
to  indicate  without  question  a  disease  of  the  bile  passages 
and  gall  bladder.  Accordingly,  on  the  23d  of  August,  I 
had  her  moved  to  a  neighboring  cottage  hospital,  where  I 
operated  for  gallstone  disease.  I  found  the  gall  bladder  and 
bile  passages  absolutely  normal;  the  duodenum  was  not 
affected;  there  was  nothing  peculiar  to  be  felt  in  the  epigas- 
trium; the  stomach  seemed  somewhat  low,  its  greater  curva- 
ture reaching  nearly  to  the  umbilicus.  I  did  not  inspect 
the  lower  portion  of  the  abdomen,  as  the  patient  was  extremely 
feeble.    However,  I  did  remove  the  appendix. 

Mrs.  Wheeler  rallied  slowly  from  the  operation.  She  was  in 
bed  for  nearly  a  month,  during  the  first  two  weeks  of  which 
the  gall  bladder  was  drained.     She  returned  home  at  length 


DIGESTIVE    DISORDERS.  1 75 

in  greatly  improved  condition,  and  for  the  next  two  months 
regarded  herself  as  on  the  highroad  to  recovery.  By  the  mid- 
dle of  November,  however,  her  symptoms  began  to  recur, 
though  in  a  modified  form.  Her  mental  state  was  deplora- 
ble; she  was  continually  on  the  verge  of  tears,  looking  upon 
herself  as  a  chronic  invalid.  Her  abdominal  pains  returned, 
though  less  severely  than  before,  and  in  a  different  location. 
Her  epigastric  pain  was  absent,  but  she  suffered  from  a  con- 
tinual abdominal  distention,  was  tender  throughout  the 
abdomen,  and  complained  especially  of  frequently  recurring 
pain  in  the  splenic  region.  Her  constipation  increased. 
For  days  she  would  lie  in  bed,  unable  to  rise  without  an 
exacerbation  of  the  pain.  Her  appetite  failed,  and  she  refused 
to  eat  anything  save  liquids.  Owing  to  her  weariness  and 
inability  to  stand  comfortably,  I  did  not  examine  her  in  the 
standing  position  until  several  weeks  had  elapsed.  When 
I  did  so,  I  concluded,  on  percussing  the  abdomen,  that  there 
was  probably  a  slight  degree  of  visceral  ptosis,  and  to  confirm 
this  suspicion  I  had  x-rays  taken,  which  I  here  reproduce. 
We  see  that,  although  the  stomach  is  not  greatly  displaced, 
there  is  a  marked  prolapse  of  the  transverse  colon,  while 
the  splenic  flexure  is  held  high,  so  that  at  that  point  there 
is  an  extreme  colonic  kink. 

Shortly  after  this  Dr.  J.  E.  Goldthwait  saw  Mrs.  Wheeler 
with  me,  and  we  agreed  upon  giving  her  a  prolonged  course 
of  proper  supports  and  exercises.  This  program  was  carried 
out  for  months,  and  in  careful  detail.  During  this  period, 
in  the  latter  part  of  May,  Mrs.  Wheeler  suffered  from  an  ac- 
cession of  mental  depression,  due  to  painful  family  circum- 
stances. Subsequently  she  went  away  for  the  summer  (1910), 
and  returned  in  the  autumn  in  much  the  same  condition 
she  was  the  year  previously,  after  the  operation.  A  series 
of  x-rays  was  again  made,  and  the  previous  diagnosis  of 
enteroptosis  was  confirmed.  In  spite  of  all  treatment  by  ap- 
paratus and  exercises,  it  became  apparent  at  length  that  we 
were  not  thus  to  succeed  in  relieving  the  patient's  discomfort. 
After  frequent  consultations,  it  was  therefore  decided  to 
operate,  with  the  object  of  relieving  the  condition  of  the  colon. 

On  opening  the  abdomen,  it  became  apparent  at  once  that 


176  SURGICAL    PROBLEMS. 

this  patient's  pain  was  due  to  the  splenic  kink  or  obstruc- 
tion. The  fecal  stream  was  forced  to  pass  upward  from  the 
pelvis,  where  the  transverse  colon  lay,  to  the  high  splenic 
flexure,  and  there  to  round  a  narrow  corner  with  the  greatest 
difficulty.  As  a  consequence,  the  whole  colon  and  much 
of  the  small  intestine  were  continually  loaded  with  gas, 
as  well  as  fecal  material.  This  exploration  was  done  for  me 
by  a  colleague,  Dr.  F.  T.  Murphy.  It  seemed  best,  in  view 
of  the  situation,  to  short-circuit  the  intestines;  accordingly, 
the  transverse  colon  was  implanted  into  the  descending  colon, 
low,  and  the  whole  splenic  flexure  was  excised. 

The  result  of  this  operation  was  satisfactory.  Mrs.  Wheeler 
rallied  well,  and  in  the  course  of  three  or  four  weeks  it  was 
apparent  that  the  function  of  her  intestines  was  renewed. 
She  was  freed  from  pain,  from  constipation,  from  distention, 
while  her  mental  condition  improved  enormously,  and  her 
general  physical  tone  as  well.  After  recovering  a  fair  degree 
of  strength  and  health  she  was  encouraged  to  take  exercises 
and  to  visit  regularly  a  gymnasium,  where  she  was  properly 
instructed.     She  is  now  a  much  improved  woman. 


Fig.  5.     Case  56. 
Showing  marked  sagging  of  transverse  colon  and  kinks  at  hepatic  and  splenic  flexures. 


DIGESTIVE    DISORDERS.  1 77 

Case  57.  The  following  case  has  in  it  certain  of  the  fea- 
tures of  Case  56.  It  is  not  final,  as  the  patient  disappeared 
during  treatment,  but  it  is  extremely  suggestive. 

Mrs.  John  Ferris  married  at  the  age  of  thirty-two,  and  sub- 
sequently bore  three  children.  On  February  19,  1910,  at 
the  age  of  forty-two,  she  consulted  me.  She  informed  me 
that  she  was  perfectly  well  up  to  her  last  confinement,  nine- 
teen months  previously,  but  that  since  then  something 
had  gone  very  wrong  with  her.  Sundry  physicians  and  sur- 
geons whom  she  named,  all  of  them  competent  persons, 
were  said  to  have  told  her  that  she  had  a  myoma  of  the  uterus, 
but  of  this  she  was  uncertain.  At  any  rate,  she  said  that  she 
had  passed  about  nine  weeks  in  bed,  two  months  after  her 
last  confinement,  and  that  she  was  curetted.  She  told  the 
tale  also  which  we  hear  so  often, — -that  the  surgeon  feared 
to  complete  the  operation  lest  she  should  die.  Such  state- 
ments are  often  pure  inventions.  Mrs.  Ferris  continued  with 
a  long  list  of  ailments.  She  said  that  after  the  curetting 
she  thought  she  had  appendicitis,  but  was  not  sure;  however, 
she  did  have  pain  in  the  region  of  the  appendix,  where  there 
was  a  swelling  or  tumor.  Ever  since  that  experience,  that 
is,  for  fifteen  months,  she  had  been  "  mad  with  a  terrible 
nervousness."  She  said  that  she  could  not  see  well  to  read; 
there  were  frequent  twitchings  of  the  hands  and  feet,  frequent 
attacks  of  intense  mental  depression  and  a  continual  weari- 
ness. All  these  symptoms  were  much  aggravated  by  the 
catamenia.  Nevertheless,  she  could  eat  well  and  sleep  well. 
She  stated,  however,  that  she  had  lost  ten  pounds  during  the 
past  week.    Her  bowels  were  acting  well.^ 

On  examing  this  woman,  I  found  her  to  look  much  younger 
than  her  given  age.  She  seemed  slightly  emaciated  and  ex- 
tremely apprehensive,  In  terror  of  some  unknown  calamity. 
Her  eyes  were  In  no  way  peculiar;  there  was  no  enlargement 
of  the  thyroid  gland,  nor  was  there  tremor,  while  the  heart 
was  in  excellent  condition,  beating  at  the  rate  of  76;  the 
chest  was  negative;  the  perineum  was  found  torn  to  the 
sphincter  and  the  cervix  badly  lacerated;  the  uterus  was 
anteverted,  while  there  was  an  excessive  uterine  catarrh; 
the  pelvic  organs  were  otherwise  not  affected.     On  examin- 


178  SURGICAL    PROBLEMS. 

ing  the  abdomen,  I  found  it  extremely  relaxed  and  the  skin 
shriveled.  She  was  a  large  woman  and  the  abdominal  con- 
tents were  easily  palpated.  Both  kidneys  were  somewhat 
prolapsed;  the  stomach  also  was  down. 

Dissatisfied  with  my  findings  and  wishing  a  further  opinion, 
I  then  sent  Mrs.  Ferris  to  an  internist,  from  whose  letter  I 
quote:  "  Aside  from  the  pelvic  condition,  I  find  both  kidneys 
loose  and  the  stomach  down  two  inches;  not  dilated.  The 
heart  is  slow,  at  60,  and  the  pulse  small.  My  idea  is  for  the 
relief  of  this  condition  to  stimulate  for  a  time  by  strychnia, 
and  to  help  the  circulation  by  the  same  means.  Also  to  give 
a  fatty  diet,  cream,  unsalted  butter,  olive  oil,  sweet  almond 
oil,  etc.,  between  meals.  .  .  .  Whether  there  is  an  intestinal 
toxemia  I  do  not  yet  know.  She  is  in  bad  enough  condition 
physically  to  have  any  old  thing.  It  may  well  be  that  the 
depression  is  due  to  an  intestinal  toxemia."^ 

This  patient  was  obliged  to  curtail  her  stay  in  Boston, 
so  that  I  was  able  only  to  assume  the  presence  of  a  consider- 
able ptosis,  my  assumption  being  founded  on  the  great  laxity 
of  the  abdomen  and  the  unsatisfactory  percussion  of  the  stom- 
ach and  colon.  However,  acting  on  the  assumption  that  there 
was  a  ptosis,  I  had  the  patient  fitted  with  a  corset-belt.  I 
have  heard  from  her  once  since  then.  She  is  certainly  better. 
Her  depression  seems  to  be  entirely  relieved,  her  pain  and 
digestive  disturbances  to  be  much  less  marked,  and  her  whole 
outlook  on  life  to  be  improved.^ 

^  This  Is  an  extremely  familiar  story,  and  suggests  the 
"  nervous  breakdown  "  which  commonly  occurs  with  married 
women  who  are  worn  out  with  household  cares  and  the  bear- 
ing and  care  of  children.  The  physician  often  finds  such  a 
woman  to  have  loose  kidneys  and  a  prolapsed  stomach. 
Indeed,  enteroptosis,  or  Glenard's  disease,  as  it  was  called, 
has  been  regarded  until  recently  as  commonly  due  to  child- 
bearing  and  the  wearing  of  tight  corsets. 

^  I  was  unable  to  arrange  for  a  proper  x-ray  In  the  case  of 
Mrs.  Ferris.  I  am  convinced  that  we  should  have  found  a 
marked  prolapse  of  both  stomach  and  colon,  especially  of  the 
colon,  when  the  patient  stood.  One  must  bear  in  mind  always 
the  great  distinction  between  the  location  of  the  stomach  and 
colon  in  the  prone  position  and  in  the  standing  position. 


DIGESTIVE   DISORDERS.  1 79 

^  The  fact  of  a  toxemia,  due  to  intestinal  fermentation, 
hinted  at  in  the  letter  of  my  consultant,  is  an  important 
matter.  Intestinal  ptosis  is  a  prime  cause  of  toxemia,  which 
may  manifest  itself  in  many  ways.  Patients  so  poisoned 
may  have  neuralgias,  myalgias,  headaches,  affections  of  the 
eyes,  mucous  colitis,  arthritis,  changes  in  temperament, 
and  very  frequently  periods  of  marked  depression,  which 
may  even  lead  to  suicidal  tendencies.  Case  56  is  an  excellent 
illustration  of  this  type. 


l80  SURGICAL    PROBLEMS. 

Case  58.  Long-continued  digestive  disorder  often  eventu- 
ates in  surprising  results  —  a  fact  familiar  to  every  prac- 
titioner. Moreover,  obstinate  cases  of  apparently  intractable 
disease  may  occasionally  seem  to  justify  unusual  and  hazard- 
ous remedies. 

Mrs.  Viola  Hone  is  a  case  in  point.  When  I  first  saw  Mrs. 
Hone,  on  the  2d  of  May,  1910,  she  was  fifty-four  years  old, 
and  had  been  much  of  an  invalid  for  twenty  years.  I  saw  her 
in  consultation  with  a  well-known  Boston  physician,  whose 
views  of  her  condition  and  the  appropriate  remedy  I  thought, 
and  still  think,  to  be  sound.  During  most  of  her  life  she 
said  she  had  been  the  victim  of  a  chronic  dyspepsia,  fluctuat- 
ing greatly  from  time  to  time,  so  that  she  had  known  periods 
of  comparative  health.  For  some  five  years  past,  however, 
her  general  condition  had  grown  materially  worse.  She  told 
me  that  her  food  had  long  ceased  to  nourish  her,  that  she  had 
lost  some  thirty  pounds  in  weight,  that  she  had  no  appetite 
and  was  made  uncomfortable  by  what  she  did  eat.  She 
was  languid  and  disheartened.  Her  distress  was  mainly 
shown  by  frequent  nausea,  general  abdominal  discomfort 
after  taking  food,  distention  with  gas,  or  bloating,  as  she 
called  it,  and  associated  pain,  felt  mainly  in  the  region  of 
the  appendix  and  in  the  region  of  the  spleen.  She  suffered 
from  an  obstinate  constipation  also.  For  some  ten  years, 
however,  her  misery  was  increased  by  a  progressive  arthritis, 
which  attacked  the  knees  especially,  though  other  joints 
also  from  time  to  time  were  involved.  As  a  result,  she  walked 
with  great  difficulty  only,  and  with  constant  pain.  She 
had  become  almost  bedridden,  and  despaired  of  her  own 
condition.^ 

On  examining  Mrs.  Hone,  I  found  her  to  be  an  emaciated, 
sad-looking  woman,  apparently  much  older  than  her  given 
age,  greatly  relaxed,  with  flaccid  muscles  and  a  flabby  ab- 
domen. Her  heart  was  somewhat  enlarged  and  there  was  an 
obvious  endocarditis,  shown  by  a  considerable  mitral  systolic 
murmur,  but  compensation  appeared  to  be  good;  otherwise 
her  chest  was  negative;  I  did  not  have  the  opportunity  of 
examining  her  in  the  standing  position,  but  the  contour  of 
her  abdomen,  which  was  long  and  narrow,  with  the  space 


Fig.  6.     Case  58. 
Note  both  flexures  displaced  downward  and  transverse  colon 


Whole  colon  sagging 
at  brim  of  pelvis,  sagging  behind  greatly  distended  sigmoid. 


DIGESTIVE    DISORDERS.  l8l 

between  ribs  and  ilium  markedly  diminished  from  the  normal, 
suggested  strongly  a  condition  of  visceral  ptosis.  This  sus- 
picion was  confirmed  by  the  x-ray,  one  of  the  plates  of  which 
I  reproduce  here. 

We  endeavored  for  some  time  to  correct  the  ptosis  and  to 
improve  the  nutrition  by  supporting  apparatus,  but  without 
material  effect.  Her  condition  continued  to  grow  worse, 
and  it  was  soon  evident  that  something  more  radical  was 
necessary;  especially  it  seemed  important  that  we  should 
enable  her  to  discharge  the  contents  of  her  colon.  There 
was  occasional  diarrhea  at  one  period  while  she  was  under 
observation,  with  profuse  dejecta  of  mucus.  This  alternated 
with  a  scybalous  constipation.  We  determined,  therefore, 
on  exploring  the  abdomen  and  doing  some  operation  which 
might  direct  the  fecal  stream  properly  towards  discharge. 
Should  her  condition  warrant  it,  some  form  of  anastomosis 
appeared  to  be  indicated;  otherwise  I  determined  upon 
establishing  a  permanent  opening  through  appendicostomy, 
and  relieving  her  by  flushing  the  colon  through  the  opening.  ^ 
Accordingly,  I  opened  the  abdomen  and  demonstrated  the 
condition  which  the  x-ray  had  already  shown.  The  ascending 
and  transverse  colons  were  in  the  pelvis,  attached  to  an  ex- 
tremely long  mesentery,  there  being  slight  retaining  bands 
at  the  beginning  and  end  of  the  cecum  only,  while  the  descend- 
ing colon  was  held  fairly  high,  in  a  relatively  normal  position. 
As  the  patient's  condition  under  the  anesthetic  was  far  from 
satisfactory,  I  determined  on  establishing  at  once  an  ap- 
pendicostomy, and  did  so,  closing  the  abdomen  without 
further  manipulation  of  the  viscera.^  On  the  day  after  the 
operation  I  opened  the  appendix  satisfactorily  and  washed 
the  colon  thoroughly,  the  discharge  issuing  in  considerable 
volume  from  the  rectum.  Twice  a  day  for  the  next  ten  days 
the  flushing  was  done,  and  with  decided  benefit.  The  patient's 
digestive  symptoms  improved  greatly,  and  she  herself  an- 
nounced that  the  pain  in  her  knees  appeared  to  diminish. 
Unfortunately,  however,  Mrs.  Hone's  general  condition  did  not 
improve.  Her  extreme  prostration,  made  worse  by  the  fail- 
ure of  proper  cardiac  action,  encouraged  a  pneumonia, 
which  set  in  rapidly  on  the  ninth  day  after  the  operation. 


1 82  SURGICAL   PROBLEMS. 

From  this  she  was  unable  to  rally,  and  in  spite  of  all  our  efforts 
she  died  of  pneumonia,  just  two  weeks  after  the  establish- 
ment of  the  appendicostomy.'* 

^  The  long-continued  arthritis  is  reasonably  attributed  to 
the  many  years  of  chronic  dyspepsia.  Our  careful  investi- 
gation of  the  case  failed  to  elicit  any  other  cause  for  the  con- 
dition of  her  joints.  This  association  is  recognized  more 
and   more   frequently  as  common  and   often   as  inevitable. 

^  The  advantages  of  appendicostomy  in  cases  of  ptosis 
associated  with  mucous  colitis  have  been  many  times  demon- 
strated. Flushing  the  colon  is  undoubtedly  of  value,  even 
though  the  flushing  be  accomplished  through  high  enemata, 
but  the  through-and-through  washing  by  appendicostomy 
is  often  an  extremely  effective  measure. 

^  In  performing  appendicostomy  it  is  well,  after  bringing 
the  appendix  outside  the  abdominal  cavity,  to  secure  it  in 
its  new  position  for  a  day  or  two  before  opening  it,  that  proper 
adhesions  may  be  formed.  The  surgeon  should  take  great 
care  also,  in  securing  the  appendix,  not  to  cut  off  the  blood 
supply,  which  is  received  mainly  through  the  meso-appendix. 
The  blood  supply  of  the  appendix  being  cut  off,  that  organ  dries 
up  and  shrivels,  so  that  the  establishment  of  a  subsequent 
and  permanent  opening  is  very  difficult. 

^  The  fatal  outcome  of  this  case  was  a  disappointment  to 
us  for  many  reasons.  The  operation  was  undertaken  practi- 
cally in  extremis,  and  our  hope  for  a  permanent  improvement 
certainly  was  never  great.  The  early  improvement,  however, 
in  the  condition  of  the  knees,  raised  our  expectations,  and 
it  seems  reasonable  to  assume  that  had  the  patient  been  able 
to  withstand  the  pneumonia  she  might  have  obtained  material,' 
and  perhaps  permanent,  benefit  from  proper  intestinal 
drainage. 

One  may  reasonably  draw  two  conclusions  from  this  case: 
First,  that  so  mild  an  operation  as  appendicostomy,  even, 
must  be  extremely  hazardous  in  the  case  of  a  patient  exhausted 
with  long  illness;  second,  that  the  temporary  improvement 
in  the  joints  which  was  secured  by  the  flushing  helps  to  con- 
firm our  belief  that  these  cases  of  arthritis  may  often  be 
dependent  upon  a  toxemia,  which  is  relieved  by  proper  treat- 
ment of  the  bowel. 


Fig.  7.     Case  59. 
Note  sigmoid,  cecum  and  transverse  colon  crumpled  together  at  brim  of  pelvis. 


DIGESTIVE    DISORDERS.  183 

Case  59.  Marion  Paoli,  at  the  age  of  four,  had  become  a 
confirmed  and  chronic  invaHd.  I  saw  her  in  consultation 
in  May,  1910,  when  she  was  under  the  care  of  a  well-known 
orthopedic  surgeon.  She  was  a  victim  of  "  chronic  rheuma- 
tism," and  had  become  nearly  blind.  She  had  run  the  gamut 
of  numerous  dispensaries  and  hospitals,  and  had  received 
in  abundance  the  conventional  joint  treatment  which  such 
institutions  supply,  but  all  without  benefit.  Her  first  and 
most  notable  ailment  was  a  chronic  arthritis,  which  had  been 
increasing  rapidly  for  the  past  three  or  four  months,  so  that 
her  knees  were  swollen  and  painful,  preventing  her  from  walk- 
ing, and  her  wrists  also  had  become  involved  in  the  process. 
For  some  six  months  also  she  had  been  afflicted  with  an  in- 
creasing failure  of  vision.  When  I  saw  her  she  could  barely 
distinguish  light  from  darkness,  and  was  said  to  have  a  form 
of  cataract  in  both  eyes.^ 

In  order  to  determine  the  possibility  of  an  intestinal  obstruc- 
tion with  a  resulting  intestinal  toxemia,  we  had  the  child 
x-rayed.  Somewhat  to  our  surprise  and  greatly  to  our  inter- 
est, the  x-ray  demonstrated  that  the  stomach  and  transverse 
colon  were  markedly  prolapsed.  The  splenic  flexure,  however, 
seemed  to  be  patent,  so  that  we  were  left  to  assume  that  the 
obstruction,  which  undoubtedly  existed  was  probably  located 
lower  down,  in  the  region  of  the  sigmoid  or  rectum.  Her 
mother  informed  me  that  her  bowels  moved  not  more  than 
once  a  week,  and  then  only  after  dosing  with  large  amounts 
of  castor  oil.^ 

So  marked  and  so  rapidly  progressive  a  toxemia  could  be 
little  influenced,  we  feared,  through  the  wearing  of  an  appara- 
tus by  so  young  a  child.  It  seemed  best  to  us,  therefore, 
to  attempt  at  once  a  radical  operation  which  should  estab- 
lish effectual,  though  temporary,  intestinal  drainage.  At 
that  time  the  problem  of  intestinal  drainage  was  not  alto- 
gether clear  to  us,  although  we  were  familiar  with  the  work 
on  that  subject  made  conspicuous  by  the  activities  of  Ar- 
buthnot  Lane,  in  London.  It  seemed  to  me  best,  however, 
to  establish  an  artificial  anus,  and  to  that  end  I  determined, 
in  the  first  place,  to  explore  thoroughly  the  abdomen.  On 
opening  the  abdomen,  on  the  14th  of  May,  I  found  the  cecum 


1 84  SURGICAL    PROBLEMS. 

and  transverse  colon  prolapsed,  as  the  x-ray  had  shown. 
The  passage  from  the  transverse  to  the  descending  colon 
was  clear,  but  lower  down,  where  the  sigmoid  flexure  passes 
the  brim  of  the  pelvis,  there  was  a  sharp  kink  or  twist,  ob- 
viously the  cause  of  the  chronic  obstruction.  At  this  point 
in  the  operation  the  child's  condition  became  so  bad  that 
I  did  not  feel  justified  in  a  further  extended  exploration. 
I  therefore  drew  out  a  loop  of  the  sigmoid  and  established 
drainage  by  colostomy  at  that  point. 

The  child  did  well;  the  wound  healed  kindly,  and  in  the 
course  of  ten  days  movements  of  the  bowels  were  free  and 
abundant  through  the  artificial  anus.  It  was  obvious  that 
we  had  accomplished  our  object  of  securing  proper  drainage. 
We  determined,  accordingly,  to  watch  the  effect  of  the  ex- 
periment to  this  point;  and  I  call  it  an  experiment  advisedly, 
for  the  situation  had  been  carefully  explained  to  the  parents 
who  agreed  that  they  would  submit  their  child  to  any  hazard, 
as  it  was  obvious  that  under  the  old  conditions  her  life  must 
be  short  and  increasingly  wretched. 

The  child's  mother  took  her  away  to  the  country  for  a 
long  summer  vacation,  and  on  their  return  in  October,  1 910, 
we  were  gratified  to  observe  a  considerable  improvement. 
The  bowels  were  moving  well  and  the  artificial  anus  was  com- 
fortably controlled  by  dressings.  The  condition  of  the 
patient's  knees  was  distinctly  better,  the  wrists  appeared 
to  be  but  little  involved  and  there  was  some  slight  improve- 
ment in  the  eyesight,  judging  from  general  appearances. 
The  child  was  rosy  and  active,  running  about  playfully  in 
my  office,  and  avoiding  without  trouble  the  furniture  in 
her  path.  She  was  able  to  distinguish  colors  also,  although 
she  could  not  recognize  individuals.  It  appeared  that  the 
time  had  now  come  to  undertake  a  further  attempt  to 
establish  a  more  comfortable  drainage  of  the  intestines.^ 

I  undertook  this  second  operation  with  a  good  deal  of  hesi- 
tancy as  I  feared  that  I  should  not  be  able  to  accomplish 
much  and  that  the  result  might  well  disappoint  us.  On  the 
15th  of  November,  I  explored  the  abdomen  again,  opening 
down  through  the  median  line  and  leaving  the  colostomy 
opening  untouched.     Hardly  was  the  abdomen  open  before 


DIGESTIVE    DISORDERS.  I85 

the  child  began  to  show  the  ill  effects  of  the  procedure,  so 
that  I  was  obliged  hastily  to  conclude  the  operation.  I 
could  only  satisfy  the  conditions  by  sidetracking  the  arti- 
ficial anus,  and  this  I  did  by  cutting  ofT  the  ileum  at  the  cecum, 
and  turning  the  proximal  end  of  the  ileum  into  the  lower  por- 
tion of  the  sigmoid,  below  the  obstruction  which  I  have 
previously  described.  The  abdomen  was  then  hastily  closed 
and  the  child  put  back  to  bed  in  extreme  collapse.  For 
some  three  days  it  appeared  that  she  would  not  rally,  but 
eventually  she  improved,  and  in  the  course  of  two  weeks 
the  wound  was  soundly  healed  and  the  child  almost  as  well 
as  ever.  For  some  weeks  thereafter  we  were  disappointed 
by  the  fact  that  fecal  discharges  issued  from  the  artificial 
anus  (backing  up  from  the  lower  sigmoid),  as  well  as  through 
the  anus  proper,  but  by  the  middle  of  December  this  double 
flow  had  become  much  less,  and  the  child's  movements  took 
place  mainly  through  the  rectum  and  anus.^  Coincident 
with  the  establishment  of  this  normal  current,  the  patient's 
general  condition  improved  greatly.  Her  arthritis  disappeared 
rapidly,  so  that  by  the  middle  of  January  it  troubled  her 
scarcely  at  all.  Moreover,  on  gross  inspection,  it  seemed  that 
the  eyes  had  improved.  At  any  rate,  she  went  about  without 
hesitation.  The  case  is  still  under  treatment,  and  a  further 
operation  undoubtedly  will  be  necessary,  an  operation  to 
close  the  artificial  anus  and  probably  to  remove  a  considerable 
portion  of  the  colon.  This  operation  we  shall  postpone, 
possibly  for  two  or  three  years,  as  it  will  be  a  tedious  under- 
taking, and  will  be  borne  better  by  the  patient  when  she  is 
somewhat  older.^ 

^  It  is  not  unreasonable  to  assume  that  a  combination 
of  arthritis  with  increasing  blindness  and  the  formation  of 
cataracts  indicate  a  profound  general  toxemia,  probably  from 
a  common  source.  Indeed,  the  competent  oculist  who  ex- 
amined this  patient  assured  us  that  the  blindness  was  cer- 
tainly due  to  some  occult  toxemia. 

^  This  case,  like  several  others  in  our  series,  appeared  to 
show  beyond  much  question  that  the  intestinal  condition 
was  the  primary  one,  and  that  the  toxemia  which  was  de- 
stroying the  child's  eyesight,  as  well  as  crippling  her  joints, 
was  due  to  the  ptosis  demonstrated  by  the  x-ray. 


1 86  SURGICAL    PROBLEMS. 

^  One  should  remember  always  in  doing  abdominal  opera- 
tions on  very  young  children  that  their  resistance  is  low, 
and  that  the  elaborate  intestinal  work  which  is  endured  by 
adults  may  well  bring  children  into  great  shock,  from  which 
frequently  they  do  not  recover. 

^  There  has  been  much  discussion  as  to  thewisdom  of  turning 
the  ileum  into  the  sigmoid  or  rectum,  because  it  is  assumed 
generally  that  that  operation,  by  sidetracking  the  colon, 
brings  about  a  condition  of  chronic  diarrhea,  the  liquid 
contents  of  the  small  intestine  being  poured  at  once  into 
the  rectum.  It  is  indeed  a  fact  that  absorption  of  water 
from  the  fecal  stream  takes  place  mainly  in  the  normal  colon, 
but  it  would  appear  that  a  certain  amount  of  absorption 
takes  place  also  in  the  sigmoid  and  rectum.  At  any  rate,  in 
the  case  of  this  child  we  have  learned  of  little  disturbance  from 
diarrhea.  I  have  now  a  series  of  six  similar  cases,  three  of 
them  operated  on  by  removal  of  the  colon,  and  none  troubled 
subsequently  by  diarrhea.  The  lower  ileum  also  expands  to 
do  the  colon's  work. 

^  This  case  has  about  it  a  good  deal  of  interest,  as  showing 
the  development  of  our  knowledge  and  studies  in  the  treatment 
of  extreme  degrees  of  ptosis  associated  with  intestinal  obstruc- 
tion. In  other  cases  of  a  similar  character  I  have  omitted 
the  preliminary  colostomy  which  we  did  here,  and  have 
at  once  shunted  the  fecal  stream  from  the  ileum  into  the 
sigmoid  flexure,  or  have  done  a  primary  removal  of  the  colon 
(colectomy). 


DIGESTIVE   DISORDERS.  1 87 

Case  60.  On  the  7th  of  July,  1910,  Dr.  Martha  Thomas, 
a  practicing  physician,  fifty-two  years  of  age,  consulted  me, 
at  the  instance  of  one  of  her  friends,  also  a  woman  physician. 
The  patient  had  practiced  medicine  for  some  twenty-five 
years,  always  under  great  nervous  strain,  for,  as  she  told  me, 
she  took  life  hard.  Moreover,  her  practice  lay  in  a  remote 
country  district,  where  the  hours,  as  well  as  the  distances, 
were  long.  She  said  that  she  never  had  been  very  vigorous, 
had  always  been  somewhat  dyspeptic,  neurotic,  and  physically 
not  up  to  her  work.  Moreover,  she  was  a  victim  of  chronic 
headache  and  constipation,  and  found  little  pleasure  or 
profit  from  food.  Now  for  some  ten  years  she  had  had  pain 
in  the  right  side  of  the  abdomen.  Two  years  before  she  had 
had  an  attack  of  bilious  colic,  which  she  thought  was  probably 
due  to  gallstones.  When  I  saw  her  she  was  the  victim  of 
remitting  attacks  of  pain  in  the  region  of  the  gall  bladder, 
pain  coming  on  perhaps  once  a  week,  lasting  several  hours 
and  easing  gradually.  She  had  never  been  jaundiced.  The 
pain  was  not  distinctly  localized,  but  seemed  to  Involve  the 
whole  upper  portion  of  the  abdomen,  epigastrium  and  right 
hypochondrlum.^  In  the  summer  of  1909  Dr.  Thomas  had 
a  fall  down  stairs,  and  struck  on  her  right  side  near  the  region 
of  the  gall  bladder.  Since  then  she  had  been  totally  inca- 
pacitated, the  pain  In  the  epigastrium  being  much  worse  than 
previously  and  rendering  any  physical  exertion  impossible. 
During  the  year  before  coming  to  me  she  had  given  up  her 
work,  and  had  called  herself  an  invalid,  passing  much  of  her 
time  In  bed.  She  was  the  victim  of  constant  fullness  and  dis- 
tress In  the  abdomen,  and  attacks  of  diarrhea  and  misery 
on  the  slightest  exertion,  with  an  unceasing  and  Indescribable 
sensation  of  discomfort  in  the  right  side.  As  she  related 
her  experiences  she  wept  and  sweated.  Two  years  before  I 
saw  her  she  had  gone  through  her  menopause.  On  further 
questioning,  she  said  that  she  experienced  a  burning  distress 
in  the  stomach  some  hours  after  taking  food.^  Her  appetite 
was  fairly  good,  except  for  breakfast,  which  she  loathed. 
She  was  continually  constipated.^ 

^  "  Bilious  "  Is  a  useful  word,  and  most  physicians  have  a 


1 88  SURGICAL    PROBLEMS. 

fairly  definite  idea  of  what  patients  mean  when  they  use  it. 
We  associate  it  with  the  term  sick  headache,  with  impaired 
digestion,  with  constipation,  with  the  conception  of  some 
obstructive  process  in  the  bile-passages,  leading  to  the  forma- 
tion of  gallstones.  Altogether  the  history  of  Dr.  Thomas's 
case  up  to  this  point  suggests  disease  of  the  bile  passages. 

2  Gastric  distress  some  hours  after  taking  food  strongly 
suggests  duodenal  ulcer. 

2  Here  is  an  interesting  train  of  symptoms,  —  biliousness, 
suggesting  gallstones;  gastric  distress  several  hours  after 
food,  suggesting  duodenal  ulcer;  lack  of  appetite  for  breakfast, 
suggesting  enteroptosis.  We  are  still  learning  and  investigat- 
ing. Enteroptosis  is  associated  with  so  many  abdominal 
diseases  that  we  are  questioning  its  causative  effect  in  those 
diseases.  We  find  cases  of  gallstones  and  duodenal  ulcer 
implanted  upon  an  old  ptosis.  In  the  case  of  Dr.  Thomas 
we  find,  in  addition,  the  familiar  ptosis  symptom  of  lack  of 
appetite  for  breakfast. 

I  found  Dr.  Thomas,  on  examination,  to  be  a  timid,  inco- 
ordinated,  flabby,  middle-aged  woman,  extremely  apprehen- 
sive and  somewhat  emaciated.  Examination  of  the  chest  was 
negative.  The  abdomen  was  greatly  relaxed  and  the  right 
kidney  very  movable.  X-ray  investigation  by  Dr.  Percy 
Brown  showed,  in  addition  to  the  ptosis  of  the  kidney,  a 
low-lying  stomach  and  greatly  prolapsed  cecum,  ascending 
colon  and  transverse  colon.  A  careful  study  of  the  gastric 
contents  failed  to  reveal  anything  significant. 

The  reader  who  has  followed  thus  far  my  description  of 
the  various  cases  of  ptosis  will  see  that  the  case  of  Dr.  Thomas 
corresponds  quite  closely  with  Cases  53,  54  and  55,  in  which 
no  x-rays  were  made.  Beginning  with  the  summer  of  1910, 
however,  I  have  made  a  careful  routine  x-ray  study  of  these 
cases,  greatly  to  the  advantage  of  the  patient,  as  well  as  of 
myself.  The  x-rays  in  the  case  of  Dr.  Thomas  made  clear 
the  need  of  proper  artificial  abdominal  supports.  Accordingly, 
I  had  Dr.  Thomas  fitted  with  a  specially  constructed  corset- 
belt,  at  the  same  time  giving  her  directions  for  exercises  and 
the  assuming  of  certain  supplementary  postures. 

She  went  home,  and  I  heard  nothing  from  her  until  the  13th 
of  October,  three  months  later.  She  then  came  to  see  me, 
and  told  a  refreshing  story.     Her  pain  had  left  her;  within 


Fig.  8.     Case  6o. 

Cecum  is  in  normal  position,  but  hepatic  flexure  has  fallen  into  pelvis,  with  a  resulting 
sharp  kink  in  ascending  colon.  The  attenuated  sagging  transverse  colon  seeks  the  high 
splenic  flexure. 


DIGESTIVE   DISORDERS.  1 89 

a  week  after  putting  on  the  support  she  had  been  freed  from 
all  digestive  symptoms,  and  began  to  feel  young  and  buoyant; 
her  appetite  returned,  her  vigor  increased,  her  ambition  was 
stimulated.  Within  two  months  she  gained  fifteen  pounds, 
and  when  she  came  to  see  me  she  was  planning  to  return  to 
that  professional  work  which  a  year  before  she  had  abandoned, 
as  she  supposed,  for  good  and  all.  She  certainly  looked  greatly 
better,  and  I  was  able  to  congratulate  myself  on  having 
secured  in  her  case  a  satisfactory  result. 


igo  SURGICAL    PROBLEMS. 

Case  6i.  Jennie  Floyd,  a  young  stenographer  of  nineteen, 
was  sent  to  me  by  her  employer  on  the  27tb;,of  July,  1910, 
because  he  feared  she  was  breaking  down,  and  because  her 
physician  had  told  her  that  she  should  be  operated  upon  for 
appendicitis.^  This  girl  was  of  a  type  and  class  extremely 
familiar;  a  New  England  girl,  brought  up  in  the  country  and 
still  living  in  a  country  town,  from  which  she  came  daily 
to  her  work  in  Boston.  One  of  a  large  family  of  children, 
and  the  daughter  of  robust  parents,  she  did  not  do  justice  in 
appearance  and  physique  to  her  undoubtedly  good  heredity. 
Her  mother,  who  came  with  her,  told  me  that  she  had  been 
a  delicate  child,  but  bright  in  school  and  active  in  play, 
when  she  was  able  to  be  about.  A  year  and  a  half  before  I 
saw  her  she  was  thrown  from  a  double-runner  in  a  coasting 
accident.  As  a  result  she  was  laid  up  in  bed  for  many  months 
with  what  was  called  nervous  prostration,  while  at  the  same 
time  she  suffered  from  an  injury  to  her  knee,  the  nature  of 
which  was  not  altogether  apparent  to  me,  though  it  would 
seem  that  her  knee  joint  had  been  laid  open  by  a  severe  blow. 
Scarcely  had  she  recovered  and  begun  to  go  about,  a  year 
before  I  saw  her,  when  she  noticed  pain  about  the  heart 
and  in  the  right  side  of  the  abdomen  after  taking  food.^ 
During  the  year  before  her  visit  to  me  Miss  Floyd  continued 
to  lead  an  uncomfortable,  semi-invalid  life,  subject  to  oc- 
casional attacks  of  epigastric  pain  and  distress,  the  pain 
extending  sometimes  into  the  chest  and  cardiac  region. 
Her  appetite  was  small  and  her  food  did  not  seem  to  nourish 
her.  She  lost  flesh,  became  easily  tired  and  suffered  much 
from  headaches.  During  most  of  this  time,  moreover,  she 
worked  as  a  bookkeeper,  the  confinement  of  which  work 
added  to  her  discomfort.  All  her  distressing  symptoms 
were  greatly  increased  by  catamenia,  at  which  time  she 
suffered  also  from  a  considerable  backache.^ 

^  Fifteen  years  ago  an  eminent  surgeon  remarked  that 
if  a  patient  complains  of  recurring  attacks  of  abdominal 
pain  the  chances  are  that  he  suffers  from  appendicitis.  This 
casual  remark  has  sunk  deep  into  the  medical  community, 
with  the  result  that  the  diagnosis  of  appendicitis  is  now 
continually  made  on  the  smallest  evidence. 


DIGESTIVE   DISORDERS.  I9I 

2  Young  girls  frequently  complain  of  this  symptom,  which 
often  resolves  itself  into  the  explanation  that  they  eat  indis- 
creetly, bolt  their  food,  take  no  care  of  the  bowels,  and  suffer 
from  indigestion,  with  gas  distention.  At  the  same  time 
one  bears  in  mind  that  patients  of  this  age  are  subject  to 
gastric  ulcer,  and  gastric  ulcer  may  well  exist  without  the 
classical  symptoms  of  extreme  pain  and  vomiting. 

^  Here  is  a  complication  of  symptoms  that  may  well  puzzle 
the  practitioner,  and  a  condition  of  invalidism  which  is 
often  a  reproach  to  the  medical  profession.  We  are  wont 
to  say  that  such  patients  are  under-nourished,  are  run  down, 
or  overworked.  We  prescribe  rest,  "  improved  hygiene," 
tonics  and  cathartics.  Such  measures  certainly  do  improve 
patients  for  a  time,  but  the  invalidism  is  rarely  cured,  and 
the  patients  relapse  after  discontinuing  the  treatment. 

I  found  this  patient  to  be  a  bright,  quick-witted  girl,  with 
rather  hectic  color,  under-developed  and  somewhat  emaciated. 
She  was  extremely  apprehensive,  and  wept  easily  on  being 
questioned.  It  was  difficult  to  examine  her,  because  she  was 
exquisitely  ticklish  —  a  familiar  symptom  with  girls  of  this 
type.  She  stood  in  a  faulty  posture,  with  shoulders  rounded 
and  dorsal  spine  flattened.  The  chest  was  negative,  the  heart 
action  good  and  the  heart  in  no  way  at  fault.  The  abdomen 
was  scaphoid,  and  while  there  was  everywhere  skin  tenderness, 
I  could  make  out  no  deep  tenderness  whatever.  As  she  stood, 
the  lower  border  of  the  stomach,  on  percussion,  appeared  to 
be  about  an  inch  below  the  navel,  with  the  colonic  tympany 
at  the  pubes.  The  appendix  could  not  be  felt,  nor  was  the 
appendix  area  sensitive.  The  abdomen  bulged  somewhat 
below  the  navel,  while  the  aortic  pulsation  in  the  epigastrium 
was  easily  felt;  indeed,  the  patient  complained  of  the 
pulsation  in  that  region. 

The  picture  I  have  drawn  here  is  classical ;  the  faulty  pos- 
ture, the  scaphoid  abdomen,  protruding  slightly  below  the 
navel,  the  neurotic  symptoms,  dyspepsia,  constipation  and  the 
lack  of  definite  localized  pain,  make  up  a  group  of  signs  and 
symptoms  which  I  have  learned  to  associate  invariably  with  a 
visceral  ptosis.    In  this  case  the  right  kidney  was  not  to  be  felt. 

I  did  not  think  it  best  at  the  time  to  secure  a  series  of  x-ray 
pictures,  but  proceeded  at  once  to  treat  the  patient  with 


ig2  SURGICAL   PROBLEMS. 

a  proper  abdominal  support  and  directions  for  the  care  of 
the  bowels,  with  sweet  oil,  carefully  graded  exercises,  the 
correction  of  posture  and  proper  hours  for  sleep.  Two  months 
later  I  learned  from  her  employer  that  she  was  very  much 
better,  and  able  to  do  her  work  with  little  effort  or  discomfort. 
The  other  day  she  informed  me  that  she  is  well. 


DIGESTIVE   DISORDERS.  1 93 

Case  62.  The  following  case,  one  of  long-continued  dys- 
pepsia, causing  discomfort  rather  than  chronic  ill-health, 
was  a  troublesome  study  for  me  through  many  years.  This 
patient  consulted  me  at  first  as  a  friend  who  might  direct 
her  to  a  proper  specialist.  I  did  so,  and  she  had  the  benefit 
of  his  care  for  two  or  three  years.  Eventually,  however,  she 
came  back  into  my  hands,  when  I  was  forced  to  regard  her  as 
a  surgical  or  rather  a  borderland  case.  It  is  a  familiar  story 
enough,  of  the  kind  that  taxes  the  patience  and  ingenuity  of 
the  physician,  leaving  him  in  the  end  little  satisfied  and  the 
patient  often  discouraged. 

Miss  Martha  Jackson  at  the  age  of  forty,  consulted  me 
in  the  summer  of  1906.  I  had  long  known  her  and  her  family 
and  was  familiar  with  her  antecedents.  She  was  a  tall, 
vigorous,  active-minded  woman,  abounding  in  good  works 
and  in  anxious  thought  for  the  prosperity  of  her  friends; 
given  little  to  considering  her  own  ailments.  She  told  me, 
however,  that  for  some  ten  years  she  had  suffered  from  a  cer- 
tain amount  of  digestive  disturbance,  which  did  not  especially 
trouble  her,  as  it  limited  her  appetite,  particularly  for  break- 
fast, so  that  she  remained  thin  and  active,  a  condition  which 
she  preferred.  Her  main  trouble  —  in  fact  her  only  trouble  — 
was  an  occasional  sense  of  soreness  and  discomfort  in  the  epi- 
gastrium and  a  frequent  condition  of  distention  or  bloating 
in  that  region,  with  eructation  of  gas. 

I  referred  Miss  Jackson  to  a  competent  internist,  under 
whom  she  throve  for  some  three  years.  He  treated  her  for 
"  hyperacidity  of  the  stomach  "  and  for  slight  gastroptosis. 
The  treatment  was  long  continued.  She  took  antacids  in 
abundance,  partook  of  an  extremely  limited  diet,  ingested 
large  quantities  of  sweet  oil,  was  active  in  light  exercis^es, 
and  submitted  to  massage;  furthermore,  she  was  fitted  with 
a  tight  corset,  which  she  felt  gave  her  a  certain  amount  of 
relief.  Throughout  most  of  the  year  1910,  she  was  so  much 
improved  that  she  ceased  to  consult  her  physician  and  went  on 
in  relative  comfort.  On  the  27th  of  November,  1910,  however, 
she  called  me  urgently  to  see  her  one  afternoon,  as  her  physi- 
cian had  left  town  for  a  long  vacation.  She  told  me  her  story 
as  I  have  related  it,   but  added  the  fact  that  for  the  past 


194  SURGICAL    PROBLEMS. 

two  days  she  had  been  feehng  decidedly  ill;  that  the  pain 
and  tenderness  in  her  abdomen  had  returned,  but  had  shifted 
to  a  lower  level;  that  the  whole  abdomen  below  the  navel 
was  extremely  tender  and  painful;  that  she  was  much  more 
bloated  than  formerly  and  was  in  misery  with  an  obstinate 
constipation  which  enemata  failed  to  relieve.^ 

A  physical  examination  disclosed  an  abdomen  somewhat 
distended  and  tender  throughout,  but  especially  tender  below 
the  navel,  and  extremely  sensitive  in  the  region  of  the  cecum. 
The  abdomen  was  everywhere  tympanitic.  There  was  no 
fever;  the  pulse  was  80.  The  right  kidney  was  palpable 
at  the  crest  of  the  ilium.  This  patient  stood  in  a  fairly  correct 
attitude,  with  her  shoulders  well  back,  but  the  dorsal  spine 
was  flattened,  while  the  lower  portion  of  the  abdomen  dis- 
tinctly protruded.  She  was  tall  and  thin,  and  was  easily 
palpated.  I  saw  her  on  two  successive  days,  during  which 
time  her  symptoms  abated  very  much.  The  posture  and  the 
contour  of  the  abdomen,  taken  with  the  train  of  symptoms, 
and  especially  with  the  fact  that  her  previous  physician  had 
discovered  a  somewhat  prolapsed  stomach,  led  me  to  believe 
that  she  might  be  suffering  from  enteroptosis,  as  well  as  gas- 
froptosis.  Dr.  Percy  Brown's  x-ray  plates,  which  I  here 
reproduce,  show  the  justness  of  this  conclusion.  They  show 
that  the  stomach  is  somewhat  prolapsed,  that  the  ascending 
and  descending  colons  are  in  fair  position,  but  that  the  trans- 
verse colon  is  well  down  towards  the  pelvis  and  is  extremely 
kinked,  or  obstructed,  at  the  splenic  flexure.  At  first,  in  view 
of  these  findings,  I  was  inclined  to  consider  an  operation 
which  should  eliminate  the  splenic  flexure,  either  by  anas- 
tomosis or  by  excision.  However,  it  seemed  best  to  try  what 
a  proper  support  would  accomplish.  For  some  months  now 
Miss  Jackson  has  been  wearing  a  carefully  fitted  corset-belt, 
and  is  free  from  any  discomfort.  The  distention  is  greatly 
less  and  the  action  of  the  bowels  is  satisfactory.  During 
this  period,  however,  she  has  had  one  severe  attack  of  pain 
and  distress,  simulating  the  one  in  which  I  first  saw  her. 
At  the  time  of  this  second  attack  her  temperature  rose  to 
101°,  and  I  was  forced  seriously  to  consider  the  possibility 
of  an   acute  appendicitis.     Careful  palpation  of  the  colon, 


Fig.  9.     Case  62. 

Unusual  displacement  downward,  forward  and  inward  of  cecum,  ascending  colon  and 
hepatic  flexure,  with  their  long  mesenteries.  The  splenic  flexure  is  high,  and  in  original 
plate  shows  sharp  kink. 


Fig.   io.     Case  62. 
Somewhat  similar  to  Fig.  9,  but  indicating  high  position  of  splenic  flexure. 


DIGESTIVE   DISORDERS.  1 95 

however,  disclosed  a  massive  fecal  impaction  in  the  cecum. 
This  was  relieved  entirely  by  one  massage  treatment.  Since 
then  Miss  Jackson  has  been  comfortable,  though  the  progress 
of  her  case  is  still  in  doubt,  and  it  may  well  be  that  eventually 
an  operation  may  be  necessary  to  secure  complete  relief.^ 

^  The  acute  attack  which  Miss  Jackson  here  describes  is 
suggestive  of  appendicitis,  and  the  physical  examination 
seemed  to  bear  out  that  diagnosis. 

2  An  interesting  incident  in  connection  with  this  last 
attack  of  pain  was  the  circumstance  that  Miss  Jackson 
was  engaged  to  attend  a  ball  on  that  very  evening.  She  felt 
that  her  attendance  was  almost  imperative.  At  the  time 
of  my  call,  which  was  in  the  morning,  I  believed  that  any  such 
gaiety  would  be  utterly  out  of  the  question.  However, 
the  active  massage  and  the  abstinence  from  food  completely 
relieved  her  by  evening.  Her  bowels  moved  thoroughly  and 
effectually,  her  other  discomforts  disappeared,  and  she 
informed  me  the  next  morning  that  she  went  through^  the 
rather  strenuous  evening  without  thinking  at  all  of  her  diges- 
tive disturbances. 


196  SURGICAL    PROBLEMS. 

Case  63.  Lysander  B.  Pettlgrew  did  not  belie  his  name. 
His  was  a  peculiar  case.  At  the  age  of  twenty-three,  and  a 
law  student,  he  was  a  solemn  young  man,  of  grave  aspect, 
given  much  to  introspection  and  endowed  with  a  feeble 
sense  of  humor.  One  afternoon  in  November,  1910,  he  pre- 
sented himself  in  my  office,  saying  that  having  casually  seen 
my  sign  in  the  window  he  thought  he  would  come  in  to  be 
examined.  Our  acquaintance,  thus  begun,  developed  rapidly. 
He  had  no  special  complaint  to  make  at  first,  but  called  on  me 
occasionally  to  discuss  the  problems  of  life.  Early  in  Decem- 
ber, however,  he  presented  himself  with  a  severe  synovitis 
of  the  left  knee.  As  this  was  subsiding,  and  in  the  course  of 
a  couple  of  weeks,  he  confided  to  me  that  he  had  always 
suffered  from  dyspepsia.  I  treated  the  matter  lightly,  but 
on  his  insisting  that  the  case  was  chronic,  and  perhaps  seri- 
ous, I  allowed  him  to  inform  me  that  for  ten  years  he  had 
suffered  from  capricious  appetite,  from  obstinate  constipa- 
tion,^ from  a  loathing  for  food  in  the  morning,  from  flatulence 
and  a  frequent  sense  of  weight,  bloating  and  oppression 
throughout  the  abdomen.  Coincidently,  his  eyes  had  become 
troublesome  and  he  had  developed  a  progressive  myopia. 

A  physical  examination  of  Mr.  Pettigrew  revealed  him 
as  a  six-foot  young  man,  erect  of  carriage,  though  inclined  to 
bow  slightly  in  the  lower  dorsal  region,  with  a  flat,  muscular 
abdomen  and  somewhat  exaggerated  gastric  tympany. 

^  Although  chronic  constipation  and  scybalous  constipation 
are  frequently  associated  with  enteroptosis,  constipation 
is  by  no  means  invariable  with  such  ptosis.  I  have  in  mind 
a  young  girl  who  suffered  from  an  extreme  degree  of  ptosis, 
her  whole  colon  being  crumpled  in  the  pelvis,  despite  which 
her  bowels  moved  freely  once  or  twice  daily,  and  she  regarded 
herself  as  having  no  digestive  symptoms  whatever. 

Had  it  not  been  for  my  experience  with  the  difficulty 
of  diagnosis  in  intestinal  cases,  I  should  not  have  thought  it 
worth  while  to  submit  him  to  an  x-ray  examination.  How- 
ever, I  did  so  submit  him,  and  with  this  interesting  result:  The 
x-ray  plate  showed  the  stomach  with  its  greater  curvature 
one   inch    below    the   navel,   the  caput  ceci,   ascending  and 


Fig.   II.     Case  63. 

Whole    colon    prolapsed.       Both    flexures    down,    especially   hepatic    flexure. 
crumpling  of  transverse  colon  near  hepatic  flexure. 


Note 


DIGESTIVE   DISORDERS.  1 97 

descending  colons  crumpled  and  much  prolapsed,  both  flexures 
being  dragged  down,  and  the  transverse  colon  below  the 
pubes. 

Mr.  Pettigrew  was  filled  with  amazement  and  interest 
when  I  explained  to  him  the  significance  of  the  x-ray  plates 
and  compared  them  with  the  normal.  He  cheerfully  accepted 
the  situation,  and  was  fitted  with  a  proper  ptosis  belt.  He 
has  worn  the  belt  for  a  few  weeks  only  at  the  time  of  this 
report,  but  already  he  asserts  that  his  sense  of  bloating  and 
discomfort  is  less  than  formerly,  that  his  constipation  is 
practically  cured,  and  that  his  outlook  on  life  is  greatly  more 
cheerful. 


BORDERLAND   CASE. 

Case  64.  One  afternoon  In  May,  1910,  a  friend  of  mine, 
Mr.  Wendell,  a  lawyer,  in  Keene,  Conn.,  telephoned  to  me 
that  his  wife,  a  woman  of  thirty,  was  flowing  severely,  and- 
asked  me  what  they  should  do.  On  inquiry,  I  learned  that 
Mrs.  Wendell  had  a  baby  one  year  old ;  that  after  the  birth 
of  the  child  she  had  had  a  comfortable  convalescence,  and 
regarded  herself  as  well  until  the  following  March,  1910, 
two  months  before  my  telephone  interview.  In  March  her 
periods  returned  as  she  supposed,  but  in  fact  she  continued 
to  flow,  and  had  been  flowing  almost  daily  —  two  months  — 
up  to  the  time  of  the  report  to  me.  The  flowing  was  sometimes 
profuse,  sometimes  trifling,  but  persisted.  As  a  result,  she 
was  becoming  discouraged  and  greatly  weakened. 

As  this  patient  was  unable  personally  to  consult  me,  and 
as  I  knew  well  her  physician  in  Keene  to  be  a  responsible 
man,  I  called  him  up,  and  learned  that  he  had  done  what  he 
could  to  remedy  the  situation.  He  said  that  the  patient's 
perineum  was  somewhat  torn,  that  her  uterus  was  slightly 
enlarged  and  prolapsed,  and  that  in  spite  of  local  treatment 
extending  over  more  than  a  month  he  had  been  unable  to 
control  the  flowing,  except  occasionally  by  large  doses  of  ergot. 
I  suggested  to  him  that  she  should  be  curetted,  to  which 
proposition  he  readily  agreed.  For  one  reason  or  another, 
however,  the  little  operation  was  postponed.  Mrs.  Wendell 
went  away  for  the  summer,  and  during  the  summer  was  con- 
siderably better,  passing  a  week  or  more  at  a  time  frequently 
without  disturbance.  During  the  following  September, 
however,  the  flowing  returned  with  increased  activity,  so 
that  on  her  consulting  me  again  early  in  October  I  determined 
to  curette  at  once. 

On  examining  the  patient  at  this  time,  I  found  her  to  be  a 
woman  of  medium  height  and  rather  heavy  figure,  with  sound 
heart  and  lungs,  general  health  excellent,  the  abdomen  large 
and  flaccid,  bearing  unmistakable  evidence  of  the  two  preg- 

199 


200  SURGICAL    PROBLEMS. 

nancies  through  which  she  had  passed.  The  uterus  had  sunk 
deep  into  the  pelvis  and  was  enlarged  to  half  again  its  normal 
size.  The  perineum  was  slightly  torn  and  the  uterine  sup- 
ports were  greatly  relaxed.^  I  was  confirmed  in  my  opinion 
that  a  curetting  should  be  done,  and  accordingly  carried  out 
thoroughly  that  operation.  I  then  opened  the  abdomen, 
raised  the  uterus  and  secured  it  high,  in  excellent  position, 
by  stitching  together  the  round  ligaments  outside  of  the  recti- 
muscles.  During  the  next  two  weeks,  while  in  bed,  Mrs. 
Wendell  felt  the  benefit  of  the  operation.  The  loss  of  vigor 
and  appetite  and  the  sense  of  dragging  in  the  pelvis,  which 
she  had  had  for  many  months,  were  completely  relieved, 
and  she  got  up  at  the  end  of  a  fortnight  feeling  more  vigorous 
than  for  years,  as  she  expressed  it.  She  was  given  the  usual 
caution  about  caring  for  herself  and  avoiding  over-exertion. 
I  thought  no  more  about  this  case  for  some  two  months 
when  I  was  called  on  the  telephone  by  Mr.  Wendell,  who 
informed  me  that  his  wife  had  again  become  a  sufferer. 
Presuming,  perhaps,  on  her  improved  health,  she  had  gone 
actively  about  her  usual  employments  until  within  a  week, 
when  she  experienced  a  sharp  attack  of  pain  in  the  neighbor- 
hood of  the  abdominal  incision.  This  was  relieved  at  once 
by  lying  down;  it  returned  when  she  stood  up;  and  thus  she 
had  gone  on  for  several  days  in  pain  and  distress  on  standing 
and  walking,  comfortable  when  lying  in  bed.  What  should 
be  done?  It  seemed  to  me  that  the  pain  was  probably 
due  to  some  dragging  on  the  uterine  adhesions.  I  called 
up  the  family  physician,  who  had  himself  seen  Mrs.  Wen- 
dell the  day  before,  and  with  an  experienced  colleague. 
Both  gentlemen  assured  me  that  the  condition  was  not 
grave,  that  nothing  whatever  could  be  discovered  on  care- 
ful physical  examination,  and  that  they  thought  it  prob- 
able the  discomfort  would  pass  off  with  a  few  days  of 
rest.  Accordingly,  Mrs.  Wendell  was  put  to  bed,  where 
she  stayed  for  a  month.  While  in  bed  she  was  perfectly 
comfortable  and  happy.  Whenever  she  got  up  and  walked 
about,  however,  the  pain  returned,  until  at  last  she  be- 
came discouraged  and  greatly  distressed.  They  telephoned 
to  me  to  go  up  and  examine  her,  which  I  did.     Here  are 


BORDERLAND    CASE.  201 

my  notes:  "  On  examination,  the  notable  feature  is  a  great 
laxity  of  the  abdominal  wall  and  an  obvious  descent  of 
all  the  viscera.  The  patient  is  perfectly  comfortable  while 
lying  down,  but  has  considerable  pain  at  the  right  of  the 
scar  when  walking.  Bimanual  examination  reveals  the 
uterus  in  excellent  position,  and  nothing  peculiar  is  felt. 
There  is  a  slight  tenderness  on  deep  palpation  at  the  right 
of  the  wound.  The  pain  complained  of  is  obviously  due  to 
a  visceral  ptosis  and  a  dragging  on  the  suspended  uterus. 
On  wrapping  the  patient's  abdomen  in  a  firm,  low,  compress- 
ing flannel  bandage,  she  experienced  immediate  relief  and 
great   comfort,    and   was   enabled   to   walk   about   without 


^  Such  a  prolapse  of  the  uterus  is  common  enough  in 
women  who  have  borne  children.  Most  surgeons  regard  it 
as  a  purely  local  condition,  and  satisfy  themselves  with 
raising  the  uterus  into  approximately  a  normal  place  and 
securing  it  by  shortening  the  round  ligaments,  or  by  some 
similar  procedure. 

2  While  it  is  true  that  for  years  we  have  recognized  the 
association  of  prolapse  of  the  pelvic  viscera  with  prolapse 
of  the  superimposed  abdominal  viscera,  the  significance 
of  this  fact  has  been  dwelt  upon  too  little.  On  considera- 
tion, one  perceives  that  it  is  inevitable  in  the  case  of  women 
who  have  borne  children  that  the  stomach,  colon  and  other 
organs  sagging  from  their  supports  must  press  down  and 
add  to  the  inevitable  ptosis  of  the  uterus  and  ovaries.  A 
realization  of  these  facts  explains  why  It  Is  that  great  num- 
bers of  women  who  suffer  after  child-birth  with  prolapse 
of  the  uterus  are  not  benefited  by  a  suspension  of  that  or- 
gan. The  mere  suspension  of  the  uterus,  while  other  or- 
gans constantly  weigh  upon  it  from  above,  must  be 
ineffective. 

A  few  days  later  Mrs.  Wendell  came  to  Boston,  where 
I  had  her  properly  and  comfortably  fitted  with  a  corset- 
belt.  She  immediately  experienced  the  greatest  relief. 
She  w^ent  home  and  continued  to  wear  the  belt.  I  have 
heard  from  her  occasionally  since  then,  and  she  assures 
me  that  she  is  well  and  strong  and  experiences  no  pain 
or  discomfort  whatever. 


TOXEMIAS. 

Case  65.  In  April,  1908,  Mrs.  B.  F.  Small  was  sent  to 
me  by  a  physician  in  Lynn,  with  the  statement  that  she  was 
suffering  from  a  marked  goiter.  The  patient  was  fifty- 
eight  years  of  age,  and  a  hard-working  housewife.  She  said  that 
her  last  catamenia  had  occurred  one  year  before  and  that 
the  flowing  lasted  six  months.  During  all  her  previous  life 
she  had  been  subject  to  severe  attacks  of  bronchitis,  and  had 
always  been  a  dyspeptic,  with  the  usual  associated  chronic 
constipation.  Four  years  before  I  saw  her,  after  an  attack 
of  bronchitis,  she  first  noticed  a  slight  swelling  of  the  neck, 
which  progressed  up  to  the  date  of  my  examination,  asso- 
ciated with  a  constant  loss  of  strength.  She  was  greatly 
depressed,  excessively  nervous,  the  victim  of  insomnia, 
suffered  from  distressing  shortness  of  breath  after  slight 
exertion,  and  believed  that  her  days  were  numbered.^ 

^  It  would  appear  at  first  sight  that  here  was  a  typical 
case  of  Graves'  disease.  Graves'  disease,  however,  is  no 
such  easy  affair  to  diagnosticate,  and,  as  the  subsequent 
history  of  this  case  illustrates,  it  may  well  be  confounded 
with  other  disorders. 

I  found  Mrs.  Small  to  be  a  fragile-looking  woman,  of  me- 
dium height,  well  developed,  but  emaciated.  The  thyroid 
gland  was  distinctly  enlarged  on  the  left,  the  lobe  being 
elastic,  movable  and  half  the  size  of  a  closed  fist.  She  wept 
easily  while  telling  her  story.  Her  eyes  were  not  prominent, 
and  an  oculist's  careful  examination  revealed  nothing  un- 
usual. As  she  spoke,  her  hands  continually  trembled,  and 
on  stretching  out  her  fingers  both  hands  showed  a  fine 
fibrillary  twitching.  Her  heart  beat  at  the  rate  of  80 ;  it  was 
slightly  enlarged  and  irregular,  but  there  were  no  mur- 
murs. The  pulse  was  of  good  quality;  all  the  reflexes  were 
normal;  the  voice  was  somewhat  rough.  On  further  investi- 
gation,  I   learned    that   the    patient  was    troubled  with  a 

203 


204  SURGICAL    PROBLEMS. 

frequent  diarrhea,  with  pains  in  the  long  bones  and  with 
indefinite  abdominal  pains;  moreover,  she  complained  of 
severe  recurring  headaches. 

I  was  in  much  doubt  as  to  the  exact  diagnosis.  Many 
of  the  symptoms,  especially  the  nervous  and  digestive 
symptoms,  pointed  surely  to  hyperthyroidism,  and  yet  the 
character  of  the  pulse  and  the  condition  of  the  heart  seemed 
to  indicate  that  such  a  diagnosis  was  not  truly  justified. 
Moreover,  in  view  of  the  patient's  psychic  state,  I  was 
disinclined  to  operate,  until  she  assured  me  that  she  had 
come  to  me  for  an  operation  and  would  abandon  all  hope 
if  operation  were  refused.  Accordingly  I  sent  her  to  the 
Massachusetts  General  Hospital,  with  the  object  of  re- 
moving the  thyroid.  I  kept  her  there  for  a  week,  resting 
quietly  in  bed.  I  regulated  the  diet  and  bowels,  and  elimi- 
nated, so  far  as  possible,  all  causes  of  mental  distress.  I 
then  removed  the  enlarged  left  lobe  entirely,  peeling  back 
the  posterior  capsule  carefully,  with  the  associated  para- 
thyroid glandules.  The  operation  was  extremely  simple, 
the  hemorrhage  slight,  and  the  patient  rallied  promptly. 
The  wound  was  soundly  healed  in  the  course  of   a  week. 

In  spite  of  the  success  of  the  operation,  however,  the 
patient  did  not  improve;  her  nervous  symptoms  persisted, 
her  headaches  persisted,  the  action  of  her  heart  remained 
unchanged.  An  examination  of  the  tumor  which  had  been 
removed  showed  it  to  be  a  simple  cystic  goiter,  without 
the  ordinary  hyperplasia  commonly  seen  in  Graves'  disease. 
Dissatisfied  with  the  result  of  the  operation,  I  then  ques- 
tioned further  and  more  carefully  the  patient  regarding 
her  previous  history.  At  length,  and  with  the  greatest 
reluctance,  she  admitted  a  fact  of  importance.  She  stated 
that  some  two  years  after  her  marriage,  twenty-five  years 
before,  she  had  suffered  from  a  long  illness,  characterized 
by  enlarged  nodes  in  the  groins,  a  persistent  skin  eruption 
and  the  loss  of  most  of  her  hair.  She  said  that  she  was 
treated  for  this  illness,  to  which  she  was  unable  to  give 
a  name,  but  that  she  feared  she  had  never  recovered  com- 
pletely. On  the  strength  of  this  history  of  syphilis,  I  insti- 
tuted a  vigorous  course  of  iodide  of  potash,  and  was  grati- 


TOXEMIAS.  205 

fied  after  a  few  weeks  to  find  that  the  patient's  symptoms 
had  entirely  disappeared,  especially  the  headache,  from 
which  she  had  suffered  for  many  years,  while  the  dyspepsia 
and  diarrhea  also  subsided. 

I  report  this  somewhat  commonplace  case,  as  it  is  an  in- 
teresting commentary  on  hasty  diagnosis,  and  suggests 
the  frequent  probability  of  associated  diseases.  Certain 
it  is  that  the  small  cystic  goiter  which  I  removed  from  the 
patient  could  scarcely  have  explained  the  severe  and  dis- 
abling train  of  symptoms  from  which  she  suffered. 


206  SURGICAL   PROBLEMS. 

Case  66.  We  are  not  wont  to  think  of  the  extreme  North- 
east Canadian  provinces  as  the  abode  of  goiter,  yet  it  would 
appear  that  Albert  County,  New  Brunswick,  is  not  a  little 
afflicted  with  that  disease.  Mrs.  Frank  Holly,  forty-five 
years  of  age,  and  a  farmer's  wife,  came  up  from  New  Bruns- 
wick to  consult  me  regarding  her  neck.  She  was  the 
mother  of  twelve  children,  and  stated  that  she  was  now 
three  months  pregnant.  Married  at  fifteen,  she  had  begun 
reproducing  at  once,  and  had  always  been  a  hard-working 
woman  in  more  ways  than  one.  She  was  a  tired  woman, 
moreover,  and  walked  heavily.  She  said  that  three  years 
previously  she  had  a  hard,  fibrous  tumor  removed  from  the 
right  axilla,  and  that  now  there  were  similar  tumors  in 
both  axillae.  During  the  past  three  years,  moreover,  she 
had  observed  an  increasing  dyspnea,  poor  accommodation 
of  the  eyes,  palpitation  of  the  heart  and  gradual  enlarge- 
ment of  the  neck.  As  a  result  of  these  symptoms,  she  was 
easily  tired  and  unable  to  do  her  usual  work.  Moreover, 
she  was  afflicted  with  a  constant  backache  and  dragging 
pains  in  the  loins,  with  bloating  of  the  abdomen,  with  con- 
stipation, with  distress  frequently  after  eating. 

On  examining  Mrs.  Holly,  I  found  her  to  be  a  large,  heavy 
woman,  somewhat  flabby;  her  eyes  were  not  peculiar,  but 
her  teeth  were  bad,  many  of  them  gone  and  most  of  the 
remainder  carious.  She  admitted  that  she  lived  on  a  diet 
of  pork  and  pie,  and  bolted  her  food.  She  was  anxious  look- 
ing, hesitant  in  speech  and  apprehensive.  Her  pulse  was 
124  to  the  minute.  There  was  no  tremor  of  the  hands, 
and  on  examining  the  axillse  I  found  them  normal.  At 
the  site  of  the  thyroid  gland  were  tumors  the  size  of  an  egg, 
on  either  side,  easily  movable  and  ascending  when  she  swal- 
lowed. On  examining  the  abdomen,  I  found  it  somewhat 
distended  and  extremely  tympanitic,  while  in  the  pelvis 
was  an  irregular  mass  connected  with  the  uterus,  evidently 
a  myoma  of  the  uterus,  and  about  the  size  of  a  closed  fist. 
The  adnexa  were  not  peculiar.  There  was  an  extensive 
laceration  of  the  perineum,  with  a  marked  cystocele. 

She  had  come  down  from  Canada  to  have  her  goiter  re- 
moved, and  the  goiter  was   the   conspicuous  lesion  which 


TOXEMIAS.  207 

appeared  to  me  most  worthy  of  treatment.  Two  days  later 
I  operated  on  Mrs.  Holly,  and  excised  a  cystic  goiter  occupy- 
ing both  lobes  and  the  isthmus  of  the  thyroid.  The  mass 
was  horseshoe  shaped,  with  a  large  middle  lobe.  I  excised 
all  three  of  the  lobes,  but  left  adherent  a  considerable 
amount  of  retrothyroid  tissue,  containing  the  parathyroid 
glandules.  The  hemorrhage  was  inconsiderable  and  the 
operation  a  simple  one.  Within  two  weeks  she  recovered 
completely   from   this   ordeal.^ 

^  The  removal  of  a  moderately  enlarged  thyroid  of  the 
cystic  type  is  not  difficult,  and  requires  no  special  knowl- 
edge or  skill,  except  that  the  surgeon  must  bear  in  mind  the 
necessity  of  saving  the  parathyroids,  while  he  must  avoid 
carefully  injury  to  the  recurrent  laryngeal  nerves.  The 
transverse  Kocher  incision  is  the  best  incision  to  use,  per- 
haps, as  it  permits  of  a  wide  exposure  and  ready  dissection 
of  the  muscles  overlying  the  gland. 

I  dismissed  Mrs.  Holly  with  the  comfortable  assurance 
that  I  had  done  everything  necessary  for  her.  One  month 
later,  however,  she  visited  me  again.  The  pulse  which 
had  been  noted  at  124  when  I  first  saw  her  was  now 
130.  Her  face  was  anxious,  there  was  some  tremor  of  the 
hands,  and  she  complained  of  increasing  lassitude  and 
dyspepsia.  It  seemed  incredible  that  we  could  be  dealing 
with  a  Graves'  disease,  as  the  histology  of  the  excised  thy- 
roid was  typical  of  cystic  goiter.  On  careful  inquiry  of  the 
patient,  however,  I  was  led  to  reconsider  the  conditions 
which  she  had  detailed  at  her  first  visit.  I  had  then  found 
a  slightly  enlarged  uterus.  She  now  informed  me  that  for 
two  years  before  consulting  me  she  had  been  troubled  with 
frequent  fiowings,  irregular  in  time  and  in  amount,  but 
that  often  she  would  dribble  slightly  for  two  or  three  con- 
secutive months.  She  said  that  since  the  operation  on  the 
thyroid  this  flowing  had  increased  and  had  begun  to  alarm 
her. 

As  I  could  find  nothing  more  in  the  pelvis  than  I  had  found 
on  my  previous  examination,  and  as  the  woman's  age  ren- 
dered suspicious   the  constant  hemorrhage,    I   saw  nothing 


208  SURGICAL   PROBLEMS. 

for  it  but  to  explore  the  pelvis  through  an  abdominal  sec- 
tion. Accordingly,  a  few  days  later  I  cut  down  upon  the 
uterus,  which  I  found  to  be  about  the  size  of  a  large  fist, 
the  fundus  rather  soft  and  boggy,  the  cervix  torn,  but  the 
womb  in  no  other  way  peculiar.  As  Mrs.  Holly  was  pre- 
sumably past  the  child-bearing  period,  I  removed  the 
uterus  (pan-hysterectomy),  and  on  opening  it  discovered 
in  the  left  cornu  a  patch  of  exfoliating  and  easily  bleeding 
new  growth,  about  the  size  of  a  silver  dime.  The  micro- 
scope showed  this  neoplasm  to  be  carcinoma. 

Recently  the  patient  reported  to  me  that  she  is  well 
and  that  there  are  no  evidences  of  further  pelvic  trouble. 
The  neck  also  causes  no  inconvenience. 

The  interest  in  this  case  rests,  of  course,  on  the  question 
of  diagnosis  and  on  the  advisability  of  a  double  operation. 
It  falls  to  every  practitioner  frequently  to  center  his  atten- 
tion upon  an  obvious  lesion,  while  he  overlooks  an  occult 
but  much  more  serious  disease.  One  says  to  oneself  that 
he  will  never  again  disregard  disease  of  the  uterus,  when 
complicated  by  an  overshadowing  disease  of  the  thyroid 
gland,  but  these  self-promises  are  difficult  to  meet,  and  one 
must  incessantly  be  on  the  alert,  if  he  would  escape  the  morti- 
fication of  overlooking  an  incipient  fatal  disease. 


TOXEMIAS,  209 

Case  67.  Diseases  of  the  thyroid  gland  are  often  pe- 
cuharly  misleading  and  difficult.  Our  diagnosis  may  be  at 
fault,  even  though  we  have  given  the  case  most  careful 
study,  and  our  prognosis  in  the  early  stages  of  certain  goiters 
is  frequently  unreliable.  The  following  brief  report  of  a  case 
illustrates  this  point. 

On  the  27th  of  April,  1908,  a  physician  who  had  made 
a  special  study  of  certain  forms  of  goiter  referred  to  me 
Mrs.  B.  N.  Hartwell,  thirty-four  years  of  age,  with  the  state- 
ment that  she  stood  in  need  of  an  immediate  operation. 
Mrs.  Hartwell  was  the  wife  of  a  physician  in  active  prac- 
tice and  of  large  experience.  She  had  always  been  well; 
in  every  way  vigorous,  steady  and  efficient.  She  stated 
that  four  weeks  before  I  saw  her  she  noticed  for  the  first 
time  a  swelling  of  the  neck.  She  said  that  this  swelling 
had  increased  rapidly  in  size;  that  almost  coincidently 
her  eyes  had  begun  to  protrude;  that  she  became  the  vic- 
tim of  an  exhausting  insomnia;  that  she  suffered  from  dis- 
taste for  food,  associated  with  an  obstinate  diarrhea;  that 
she  was  continually  and  extremely  nervous,  and  that  she 
felt  herself  to  be  growing  rapidly  ill. 

On  examining  Mrs.  Hartwell,  I  found  that  her  statement 
regarding  her  physical  condition  was  fairly  accurate.  There 
was  an  obvious  enlargement  of  the  left  lobe  of  the  thyroid, 
the  tumor  being  about  the  size  of  a  small  hen's  egg.  There 
was  also  a  noticeable  protrusion  of  both  eyes,  with  lagging 
of  the  lids  and  difficulty  in  accommodation.  She  was  flushed, 
and  perspired  easily;  she  was  haggard  and  anxious  looking, 
and  appeared  decidedly  emaciated.  The  heart  was  beating 
at  120,  and  was  accelerated  to  140  on  the  slightest  exertion. 
It  did  not  seem  to  be  enlarged,  however,  and  there  was 
no  evidence  in  it  of  any  organic  change.  Here  was  a  case 
which  was  obviously  one  of  acute  Graves'  disease.  Nearly 
all  the  classical  symptoms  were  present  and  the  progress 
of  the  ailment  was  alarming.  My  consultant  had  sent  the 
patient  to  me  for  an  immediate  operation,  and  he  felt  that 
temporizing  measures  would  be  futile.  My  own  judgment 
coincided  with  his  in  the  main,  except  that  I  hesitate  always 
to  operate  on  the  most   severe  acute  cases  without  giving 


210  SURGICAL    PROBLEMS. 

them  the  benefit  of  a  few  days'  rest,  and  watching  the  effect. 
In  this  particular  case,  moreover,  both  Dr.  Hartwell  and 
his  wife  urged  that  an  immediate  operation  would  be  ex- 
tremely inconvenient,  and  asked  that  it  might  be  postponed 
for  at  least  a  week.  Dr.  Hartwell  promised  that  he  would 
send  his  wife  to  a  sanatorium,  where  she  might  be  under 
the  most  careful  observation  and  have  the  benefit  of  an 
absolute  rest  cure.  I  consented  to  this  arrangement  on  the 
understanding  that  should  the  symptoms  increase  I  should 
be  notified  at  once. 

I  heard  nothing  more  from  this  patient  for  two  weeks. 
At  the  end  of  that  time  I  was  surprised  and  gratified  to  re- 
ceive a  long  and  satisfactory  letter  from  Dr.  Hartwell. 
He  reported  to  me  that  apparently  as  a  result  of  the  rest 
cure  his  wife's  goiter  had  so  decreased  in  size  as  to  be  barely 
perceptible,  that  her  eye  symptoms  had  practically  dis- 
appeared, and  that  she  was  freed  of  all  her  other  distressing 
symptoms.  She  remained  for  some  weeks  longer  in  the 
sanatorium.  During  the  past  three  years  I  have  had 
occasional  reports  from  this  case,  all  of  them  satisfactory 
and  indicating  that  there  has  been  no  return  of  serious 
symptoms. 


TOXEMIAS.  211 

Case  68.  Mrs.  A.  Sylvester  was  a  woman  of  forty-two. 
She  had  behind  her  a  long  surgical  history, —  operations 
for  salpingitis,  for  retroperitoneal  cyst,  for  ovaritis, —  but 
in  spite  of  these  serious  diseases  and  operations,  which 
occupied  many  years  of  her  younger  life,  she  emerged  strong 
and  vigorous.  At  the  age  of  thirty-seven,  however,  she  con- 
sulted her  physician  for  what  appeared  to  be  a  trifling  heart 
lesion,  for  she  found  herself  troubled  with  occasional  dyspnea 
on  exertion.  Her  physician  discovered  a  slight  mitral  leak 
and  some  dilatation  of  the  heart.  Careful  treatment  and 
prolonged  rest  resulted  in  no  benefit;  gradually  there  de- 
veloped further  a  constant  distressing  dyspepsia,  pain  and 
nausea  after  eating  and  a  state  of  continual  apprehension. 
These  symptoms  persisted  for  two  years,  when  there  de- 
veloped further  a  mild,  bilateral  tremor  of  the  fingers.  At 
this  stage  she  consulted  me,  on  the  advice  of  her  physician, 
and  I  was  able  to  suggest  the  diagnosis  of  exophthalmic 
goiter.  Even  so,  the  diagnosis  was  by  no  means  assured, 
for  no  enlargement  of  the  thyroid  was  evident,  nor  were 
there  marked  eye  symptoms,  while  the  heart  rate  rarely 
went  above  80.  We  continued  to  treat  her  as  a  cardiac 
case  only  —  bearing  in  mind  the  possibility  of  Graves' 
disease  —  for  another  year,  when  within  a  month  there 
developed  a  series  of  characteristic  symptoms:  the  thyroid 
gland  became  enlarged,  with  a  typical  thrill;  the  eyes  gradu- 
ally became  prominent,  with  lagging  of  both  lids  and  wid- 
ening of  the  palpebral  fissure;  and  tachycardia  became 
pronounced,  the  rate  of  the  heart  ranging  between  no  and 
130. 

Here  was  a  case  which,  in  spite  of  its  gradual  onset,  seemed 
suitable  for  immediate  and  vigorous  medical  treatment. 
Accordingly,  we  instituted  the  use  of  hydrobromate  of  qui- 
nine, neutral,  in  5-gr.  capsules,  three  times  a  day,  and  con- 
tinued the  medication  without  intermission  for  fifteen 
months.  During  the  early  months  of  treatment  the  pa- 
tient experienced  great  relief;  her  apprehension  vanished 
her  thyroid  tumor  became  somewhat  smaller,  the  heart 
action  became  slower  and  her  general  sense  of  improvement 
marked.     Such  was  her  state  twelve  months  after  the  be- 


212  SURGICAL    PROBLEMS. 

ginning  of  the  quinine  treatment.  Slie  was  not  well,  how- 
ever, and  her  condition  of  instability  became  especially 
apparent  at  that  time  through  the  accident  of  a  serious 
grief;  a  favorite  sister  became  ill,  and,  after  a  month's  ex- 
treme suffering,  died,  under  the  constant  watchfulness 
of  our  patient.  The  strain  and  anxiety  of  this  experience 
renewed  at  once,  and  markedly,  the  Graves'  symptoms. 
Within  a  very  few  weeks,  from  the  state  of  quiescence  I 
have  described,  all  her  discomforts  reappeared;  the  eyes 
became  prominent  and  anxious,  with  their  associated  ab- 
normal lid  phenomena;  her  tachycardia  returned;  the  heart 
became  irregular ;  dyspnea  became  extreme ;  she  was  troubled 
with  a  constant  diarrhea  and  distaste  for  food ;  profuse  sweat- 
ing became  pronounced;  the  tremor  returned  in  force;  and 
the  right  lobe  of  the  thyroid  doubled  in  size. 

Now  the  case  presented  all  the  typical  symptoms  of  acute 
Graves'  disease,  and  demanded,  apparently,  most  ener- 
getic treatment.  Fortunately,  during  the  whole  of  this 
period  she  had  been  under  constant  medical  care  and  I 
had  seen  her  myself  once  a  month  for  more  than  a  year. 
The  hydrobromate  of  quinine  appeared  to  be  no  longer 
useful,  and,  in  view  of  the  rapid  development  of  her  acute 
symptoms,  it  seemed  wise  to  me  to  undertake  a  radical 
operation;  at  the  same  time,  in  view  of  her  alarming  psychic 
state,  I  made  every  attempt  to  bring  her  to  the  operation 
in  a  calm  frame  of  mind.  I  believe  firmly  in  the  value  of 
Crile's  suggestion  regarding  psychic  influences  in  acute 
Graves'  disease,  and  in  the  importance  of  bringing  the 
patient  to  operation  practically  without  her  knowledge. 
In  the  present  case  I  followed  the  plan  which  I  always  insti- 
tute in  similar  acute  cases.  The  probability  of  our  doing 
an  operation  was  explained  to  the  patient  and  her  con- 
sent to  it  was  secured,  as  well  as  the  consent  of  her  relatives, 
but  the  exact  time  of  the  operation  was  not  set,  nor  was  the 
operation  explained  to  her  as  inevitable.  I  sent  her  to  a 
quiet  private  hospital,  confined  her  to  her  room,  with  a  con- 
genial nurse,  and  kept  her  there,  resting  and  closely  observed, 
for  ten  days.  She  spent  her  time  in  bed.  I  was  able  to  re- 
lieve the  sleeplessness  from  which  she  suffered  by  the  liberal 


TOXEMIAS.  213 

use  of  bromide  of  strontium,  and,  through  the  inhalation 
of  various  volatile  oils  and  colognes,  to  suggest  to  her  the 
possibility  of  improvement.  During  those  ten  days  she  was 
treated  every  morning  by  inhaling  either  nitrous  oxide, 
eucalyptus,  alcohol,  spirits  of  camphor,  ether  or  cologne, 
all  in  small,  harmless  amounts  and  freely  mixed  with  air. 
In  this  way  she  acquired  the  idea  of  taking  inhalations 
without  the  slightest  terror  or  distress. 

The  principle  of  this  treatment,  as  enunciated  by  Crile, 
rests  on  the  following  proposition:  We  know  that  the  acute 
phenomena  of  Graves'  disease  are  due  to  the  abundant 
outpouring  of  the  thyroid  gland  secretion  into  the  lym- 
phatics and  so  into  the  general  circulation;  we  know  that 
this  outpouring  can  be  increased  by  such  stimuli  as  fear, 
anxiety  and  even  mirth,  but  fear  and  anxiety  are  especially 
deleterious.  Clinical  evidence  shows  that  the  ordinary 
preparation  for  operation  and  the  giving  of  ether  have, 
through  the  stimulus  of  fear,  more  than  once  killed  a  patient, 
from  the  sudden  resulting  outpouring  of  thyroid  intoxi- 
cants, without  any  operation  having  been  done.  If,  then, 
we  can  bring  the  patient  to  the  operation,  can  produce 
anesthesia  and  can  operate  without  altering  the  equanimity 
of  the  patient's  mental  attitude,  we  are  convinced  that 
we  then  operate  under  the  most  favorable  conditions. 

I  followed  this  method  with  the  patient  under  discussion. 
On  the  morning  set  apart  for  the  operation  she  realized 
no  change  in  the  ordinary  routine.  She  was  indeed  given 
a  hypodermic  of  morphia,  but  she  had  been  given  hypoder- 
mics of  sterilized  water  daily,  so  that  a  hypodermic  of  mor- 
phia impressed  her  mind  not  at  all.  An  hour  after  the  hypo- 
dermic, when  she  was  in  a  calm  and  untroubled  state,  I 
myself,  as  had  been  my  custom,  entered  her  room  and 
proceeded  with  the  anesthetic,  giving  her  first  a. few  whiffs 
of  cologne,  then  an  abundant  inhalation  of  nitrous  oxide, 
with  a  little  oxygen,  and  then,  when  consciousness  was  gone, 
had  the  anesthesia  carried  on  by  ether.  This  was  more  than 
a  year  ago.  My  present  custom  is  to  carry  the  patient 
through  the  operation  with  nitrous  oxide  and  oxygen,  as 
I  am  convinced  that  thus  her  resistance  can  be  kept  nearest 


214  SURGICAL    PROBLEMS. 

to  its  normal.  The  patient  was  carried,  anesthetized,  to 
the  operating  room,  and  these  interesting  facts  were  noted: 
Before  taking  her  anesthetic  her  pulse  had  been  no,  when 
completely  anesthetized  her  pulse  was  112;  during  the  re- 
moval of  the  gland  her  pulse  varied  between  100  and  no; 
half  an  hour-after  her  return  to  her  room,  and  while  recovering 
from  the  anesthetic,  her  pulse  reached  120,  but  three  hours 
later  it  had  fallen  to  90. 

This  Is  In  notable  contrast  with  the  ordinary  experience 
of  bringing  a  terrified  patient  to  the  operation,  when  dur- 
ing that  operation  we  note  a  steadily  rising  pulse  and  a  con- 
dition often  of  great  gravity  before  the  recovery  from  ether. 

The  operation  In  the  present  case  was  a  simple  one;  It 
consisted  in  removing  the  left  lobe  of  the  thyroid,  stripping 
the  posterior  capsule  after  the  method  of  C.  H.  Mayo,  in 
the  removal  of  the  isthmus  and  the  removal  of  about  one 
third  of  the  right  lobe. 

After  the  operation,  and  with  the  patient's  recovery  from 
ether,  all  acute  interest  In  the  case  ceased;  though  one  was 
struck,  as  one  always  Is  in  satisfactory  cases,  to  observe 
her  rapid  and  complete  recovery  of  health.  The  first  no- 
ticeable change  was  the  loss  of  peevish  irritability  which  had 
characterized  her  before.  She  was  relatively  calm  and  tran- 
quil after  the  operation,  and  two  days  later  had  ceased  en- 
tirely to  complain  of  any  operative  sore  throat  and  pain 
in  her  neck.  Colncidently,  one  observed  a  steadying  of  the 
pulse  and  a  gradual  decline  in  its  rate;  the  tremor  also 
abated  rapidly ;  dyspnea  was  never  again  observed ;  the  sweat- 
ing disappeared,  and  at  the  end  of  ten  days  her  digestive 
disorders  were  greatly  improved.  The  wound  healed 
promptly  and  never  disturbed  us.  The  most  noticeable 
fact,  however,  about  this  case,  as  about  all  successful  cases, 
was  the  calm,  happy  and  tranquil  attitude  of  the  patient 
herself.  One  may  not  in  words  clearly  define  this  change, 
but  It  Is  so  rapid  and  so  striking  in  all  successful  cases  that 
it  suggests  the  relief  brought  by  the  timely  and  appropri- 
ate use  of  morphia  to  a  person  in  pain  and  terror.  It  is 
the  reverse  of  euthanasia;  it  is  the  confident  return  to  a 
cheerful  and  comfortable  life. 


TOXEMIAS.  215 

The  operation  I  have  described  was  done  some  eight 
months  ago,  and  I  have  seen  the  patient  four  times  since 
she  left  the  hospital.  It  is  too  early  as  yet  to  pronounce 
her  permanently  cured;  indeed,  one  symptom  still  remains, 
—  a  slight  exophthalmos, —  but  in  all  other  respects  she 
appears  and  feels  absolutely  well  and  goes  about  her  work 
in  life  with  a  vigor  and  a  cheerfulness  which  she  had  not 
known  for  five  years. 

This  case,  in  its  later  developments,  was  a  typical  acute 
Graves',  and  in  its  ready  yielding  to  treatment  illustrates 
admirably  the  value  of  operation  in  proper  cases.  In  no 
way  was  it  especially  remarkable  except  in  the  long  and  grad- 
ual onset  of  the  symptoms  and  in  the  sudden  accession  of 
serious  symptoms  on  the  experience  of  a  depressing  grief. 


2l6  SURGICAL    PROBLEMS. 

Case  69.  At  the  age  of  twenty-six,  Annie  McPhee  was 
a  pronounced  "  neurasthenic."  She  was  a  housemaid, 
who  had  been  obliged  to  give  up  her  work.  She  Hved  in 
fear  of  some  operation,  its  nature  unknown.  She  com- 
plained bitterly  of  headaches,  of  constipation,  of  distress 
after  eating,  of  blurring  of  vision,  of  great  nervousness, 
of  insomnia,  and  of  sundry  indefinite  pains  in  her  chest, 
abdomen  and  legs.  She  felt  that  she  was  going  into  a  de- 
cline, and  she  was  extremely  despondent.  This  patient 
had  been  treated  for  many  years  for  neurasthenia,  and  had 
consumed  countless  drugs;  she  had  been  sent  away  on 
long  vacations;  she  had  been  referred  to  a  sanatorium; 
but  all  without  avail.  Her  most  pronounced  symptoms 
appeared  to  be  digestive,  and  it  was  with  the  thought  of 
some  digestive  disturbance  that  I  examined  her. 

She  was  a  young  woman  who  had  had  no  catamenia  for 
three  years.  She  was  anxious  of  aspect  and  wept  easily. 
As  she  entered  my  office  I  noticed  that  her  gait  was  slow, 
her  expression  timid,  her  attitude  shrinking  and  her  pos- 
ture faulty.  She  stood  with  protruding  shoulders,  flattened 
back  and  trembling  hands,  which  hung  twitching  at  her 
sides. ^  On  examining  her  I  was  at  first  convinced  that  my 
"snap"  diagnosis  would  meet  the  bill.  There  seemed  no 
question  that  she  was  suffering  from  a  pronounced  entero- 
ptosis,  doubtless  congenital,  exaggerated  during  recent  years, 
a  common  cause  of  neurasthenic  symptoms.  If  I  had  gone  no 
further  than  an  examination  of  the  standing  patient,  I 
should  have  concluded  that  she  was  in  need  of  treatment 
for  the  ptosis  only.  On  investigating  further,  sundry  other 
signs  and  symptoms  were  discovered.  She  was  a  hectic 
girl,  with  a  slight  exophthalmos.  The  pulse  rate  was  150, 
the  pulse  bounding.  Her  heart  was  dilated,  the  apex  being 
in  the  nipple  line.  She  flushed  easily  and  sweated.  There 
was  an  extremely  marked  fibrillary  tremor  of  the  extended 
fingers.  In  the  neck  was  a  tumor  of  the  thyroid  the  size 
of  a  man's  fist,  uniform  and  smooth,  mostly  on  the  left 
side.  The  whole  picture  was  one  of  a  marked  Graves' 
disease.^ 


TOXEMIAS.  217 

^The  appearance  of  this  patient  is  almost  characteristic, 
suggesting  at  once  a  marked  form  of  enteroptosis.  More- 
over, the  history  of  dyspepsia  seemed  to  bear  out  that  sug- 
gestion. Victims  of  marlced  enteroptosis  assume  almost 
invariably  the  faulty  posture  I  have  described.  Their  ab- 
domens are  long  and  more  or  less  boat-shaped,  protruding 
below  the  navel,  while  the  costo-iliac  space  may  be  extremely 
short,  owing  to  the  downward  reach  of  the  floating  ribs. 
All  of  these  signs  were  present  in  the  case  of  Miss  McPhee. 

2  The  possible  relation  between  enteroptosis  and  Graves' 
disease  is  a  problem  not  yet  solved  and  subject  to  numer- 
ous hypotheses.  The  first  proposition  regarding  the  fact 
of  enteroptosis  is  that  it  causes  an  intestinal  stasis,  asso- 
ciated with  fermentation  and  a  varying  degree  of  toxemia. 
This  proposition  is  proven.  The  further  possibility,  however, 
of  a  relation  between  the  toxemia  of  ptosis  and  its  effect 
on  certain  structures,  such  as  the  ductless  glands.  Is  not  yet 
apparent.  An  interesting  fact,  however,  is  this,  ■ —  that 
enlargements  of  the  thyroid,  especially  enlargernents  of  the 
thyroid  associated  with  Graves'  disease,  are  not  infrequently 
encountered  in  patients  who  are  the  victims  of  entero- 
ptosis. Certain  students  of  the  problem  are  coming  to  believe 
that  Graves'  disease,  as  well  as  other  diseases  of  ductless 
glands,  should  be  studied  in  connection  with  the  phenomena 
of  ptosis.  I  have  now  a  series  of  thirteen  consecutive  cases 
of  Graves'  disease  in  women,  all  associated  with  marked 
enteroptosis. 

At  the  time  of  Miss  McPhee's  consulting  me  I  had  not 
learned  to  appreciate  entirely  the  possible  significance  of 
enteroptosis,  and  while  I  recognized  its  presence  In  the  pa- 
tient under  discussion,  I  felt  that  the  urgent  and  serious 
symptoms  of  Graves'  disease  demanded  immediate  treat- 
ment. 

Accordingly,  I  sent  the  patient  to  a  hospital,  and  insti- 
tuted a  short  course  of  rest  treatment,  with  the  purpose 
of  operating  upon  the  gland  by  the  method  of  Crile.  This 
method  consists  in  "  stealing  away  "  the  gland.  As  is  well 
known,  Crile's  proposition  rests  on  the  fact  that  the  psy- 
chic influences  surrounding  a  surgical  operation,  the  terror 
and  the  anxiety  caused  thereby,  will  almost  always  exagger- 
ate the  serious  symptoms  of  acute  Graves'  disease.  It 
Is  well  known  that  Graves'  patients  anticipating  an  oper- 


2l8  SURGICAL    PROBLEMS. 

atlon  are  apt  to  become  worse;  that  their  pulse  rate  runs 
up,  their  temperature  is  constantly  high,  and  that  their 
other  symptoms  grow  rapidly  more  and  more  troublesome. 
With  the  object  of  saving  this  patient  anxiety,  and  bring- 
ing her  in  a  proper  state  to  the  operation,  I  followed  Crile's 
suggestion  of  keeping  her  quiet  for  a  number  of  days,  employ- 
ing bromides  for  sleep,  and  using  a  variety  of  inhalations 
daily,  which  should  accustom  her  to  the  idea  of  taking  an  anes- 
thetic. Although  I  had  this  patient's  consent  to  an  opera- 
tion, I  had  not  assured  her  of  its  being  inevitable,  nor  had 
I  suggested  a  day  for  its  performance.  Ten  days  after 
her  removal  to  the  hospital  I  found  that  many  of  her  symp- 
toms had  decidedly  abated;  the  pulse  was  ranging  between 
95  and  105,  there  was  little  or  no  fever,  and  she  was  sleep- 
ing fairly  well.  Accordingly,  one  morning,  at  the  time  when 
she  usually  practiced  her  inhalations,  I  substituted  nitrous 
oxide  for  the  customary  volatile  oils  and  air,  and  induced 
a  rapid  anesthesia.  I  then  carried  her  to  the  operating 
room  and  removed  the  whole  of  the  right  lobe,  leaving  the 
posterior  capsule;  and  I  removed  about  two  thirds  of  the 
left  lobe. 

The  patient  stood  the  operation  extremely  well.  Her 
pulse,  which  was  100°  at  the  beginning  of  her  inhalations, 
rose  to  110°  only,  and  subsided  to  90°  at  the  close  of  the 
operation.  There  was  no  difficulty  in  the  operative  technic; 
the  portions  of  the  gland  were  readily  removed  and  the 
hemorrhage  was  inconsiderable.  The  wound  was  closed 
and  drained  as  usual. 

There  is  nothing  to  "record  further  concerning  the  con- 
valescence, which  was  steady  and  satisfactory,  so  that  at 
the  end  of  two  weeks  the  patient  left  the  hospital  greatly 
improved.  This  was  by  no  means  the  end  of  the  case,  how- 
ever. Miss  McPhee's  ptosis  remained,  and  although  her 
heart  action  was  satisfactory,  her  dyspnea  slight,  and  her 
courage  and  ambition  good,  she  still  suffered  much  from 
dyspepsia,  from  constipation,  from  headache  and  from 
general  lassitude.  These  symptoms  I  regarded  as  possibly 
due  to  the  underlying  ptosis.  I  therefore  had  her  fitted  with 
a  satisfactory   abdominal   support.     She   has  worn   it   con- 


TOXEMIAS.  219 

stantly  now  for  nearly  three  years.  She  has  improved  greatly 
in  general  health;  she  has  gained  thirty  pounds  in  weight, 
insomnia  has  disappeared,  her  digestion  is  fair  and  her  vigor 
excellent.  She  is  again  at  work,  and  regards  herself  as  rela- 
tively well. 


220  SURGICAL   PROBLEMS. 

Case  70.  This  case  was  atypical:  Mrs.  T.  Burgess  was 
a  vigorous  young  woman,  of  active  habits,  some  thirty- 
two  years  of  age,  and  the  mother  of  four  children.  With 
the  exception  of  her  obstetrical  history,  there  was  nothing 
in  her  past  life  of  any  special  significance.  She  had  always 
been  regarded  as  particularly  sane  and  well-balanced.  Some 
two  years  before  I  saw  her  she  suddenly  became  extremely 
nervous;  within  a  week  she  took  on  symptoms  that  sug- 
gested to  her  physician  a  rapid  neurotic  breakdown;  she  was 
sleepless,  fretful,  irritable  and  almost  impossible  to  live  with, 
as  her  friends  asserted.  Within  a  week  after  the  surprising 
development  of  these  symptoms  her  physician  discovered 
a  marked  tumor  of  the  thyroid  gland.  There  was  no  other 
evidence  of  hyperthyroidism,  with  the  exception  of  the  nerv- 
ousness; there  was  no  exophthalmos,  no  tachycardia  or 
palpitation,  or  tremor,  no  digestive  disturbance,  no  sweat- 
ing; in  fact,  the  diagnosis  was  founded  almost  solely  on  the 
nervousness  and  the  rapidly  enlarging  thyroid. 

The  patient's  physician  had  the  courage  of  his  convic- 
tions and  his  convictions  were  sound  and  accurate.  With- 
out stopping  to  employ  drugs,  and  without  waiting  to  see 
the  development  of  the  case,  he  proceeded  at  once  to  a  sur- 
gical operation,  and  his  surgical  activity  seems  to  have  been 
justified  by  the  results.  He  removed  the  whole  of  the  left 
lobe  of  the  thyroid,  leaving,  however,  the  isthmus,  with 
a  considerable  pyramidal  lobe,  and  the  whole  of  the  right 
lobe.  The  lobe  removed  was  much  the  more  affected;  those 
parts  which  were  left  seemed  to  be  but  slightly  hypertro- 
phied. 

Mrs.  Burgess  promptly  recovered  from  the  operation 
and  promptly  regained  her  normal  health.  Her  nervousness 
disappeared,  and  her  usual  cheerful  and  equable  tempera- 
ment was  restored  to  her.  Her  husband's  later  account 
to  me  of  the  year  which  followed  was  encouraging,  if  it  had 
not  been  pathetic.  At  any  rate,  the  operation  showed  bril- 
liantly the  immediate  relief  of  cutting  out  a  greatly  active 
gland  which  obviously  was  pouring  toxins  into  the  patient's 
organism.  Mrs.  Burgess's  after-history,  however,  was  stormy 
and  instructive.     Her  symptoms  of  hyperthyroidism  gradually 


TOXEMIAS.  221 

returned  after  a  year  and  became  more  settled  and  more 
pronounced  than  before.  Not  only  was  she  the  victim  of 
an  intense  nervousness  on  this  second  occasion,  but  she 
developed  many  of  the  classical  symptoms  of  Graves' 
disease;  her  eyes  became  prominent,  with  the  usual  associated 
lid  symptoms;  the  remaining  lobes  of  the  gland  became 
enlarged  to  about  four  times  their  normal  size;  tachycardia 
developed,  though  not  in  an  extreme  degree,  but  her  pulse 
came  to  range  between  lOO  and  no;  she  became  the  vic- 
tim of  dyspnea  and  palpitation,  while  her  digestive  disturb- 
ances were  poignant, —  pain  after  food,  eructations  and 
constant  diarrhea, —  associated  also  with  rapid  emaciation. 
Such  was  her  condition  when  she  consulted  me,  some  four- 
teen months  after  the  first  operation. 

I  endeavored  for  some  time  to  relieve  her  symptoms 
and  to  build  her  up  by  the  use  of  hydrobromate  of  qui- 
nine, but  at  the  end  of  eight  weeks  she  was  little  im- 
proved, and  the  outlook  began  to  appear  very  serious. 
Meantime  her  husband  and  her  physician,  who  had  per- 
formed the  first  operation,  both  urged  me  strongly  to 
proceed  with  a  second  operation.  It  seemed  to  them  that 
the  failure  of  the  first  operation  to  effect  a  cure  was  due 
to  the  incompleteness  of  the  work.  It  was  said,  with  ap- 
parent justice,  that  much  more  of  the  affected  thyroid  should 
have  been  removed.  At  this  time,  that  is  to  say,  immediately 
before  my  own  operation,  which  I  undertook  with  some 
hesitation,  the  patient,  while  extremely  ill  in  the  thyroid 
sense,  seemed  to  be  an  excellent  surgical  risk.  She  had 
herself  well  in  hand  and  exhibited  little  of  the  terror  and 
perturbation  which  these  people  usually  show  when  an  oper- 
ation is  anticipated;  indeed,  it  did  not  appear  to  me  that 
my  usual  course  of  psychic  treatment  was  indicated;  the 
patient  was  so  perfectly  familiar  with  her  coming  ordeal, 
and  so  keenly  intelligent  about  preparing  for  it,  that  I  thought 
it  best  to  consult  her  about  the  day  and  the  circumstances 
of  the  operation. 

On  the  appointed  day  she  walked  to  the  operating  room 
herself  to  take  her  anesthetic,  and  appeared  reasonably 
placid.      Her   pulse   was    io6,   of   fair  quality,    but   slightly 


222  SURGICAL    PROBLEMS. 

intermittent.  There  were  no  evidences  of  degenerative 
changes  in  the  heart  or  nervous  system,  though  a  slight, 
hemic,  mitral  murmur  was  obvious;  the  heart,  however, 
was  not  enlarged.  I  anesthetized  this  patient  with  gas 
and  oxygen  with  the  greatest  immediate  success.  The 
combination  of  these  agents  is  usually  peculiarly  effective 
in  cases  of  Graves'  disease.  At  the  same  time,  in  order  to 
block,  so  far  as  possible,  the  effects  of  hyperthyroidism,  I 
followed  the  later  suggestion  of  Crile  and  infiltrated  the  skin 
about  the  tumor  thoroughly  with  a  i%  cocaine  solution. 
I  found  the  operation  of  thyroidectomy  in  this  case  un- 
usually difficult.  The  previous  operation  had  had  the 
common  effect  of  filling  the  operative  field  with  extensive 
and  dense  scar  tissue,  through  which  there  was  an  abun- 
dant blood  supply.  This  dissection  was  most  painstaking 
and  bloody,  though  the  total  amount  of  hemorrhage  or 
of  blood  lost  was  inconsiderable,  I  am  convinced.  At  one 
time  I  counted  47  hemostatic  forceps  in  the  field  of  opera- 
tion, and  I  am  sure  there  must  have  been  twice  that  number 
before  the  operation  was  completed.  All  this,  of  course, 
shows  the  difficulty  of  the  operation  and  its  length.  The 
thyroid  lobes  seemed  everywhere  closely  adherent  to  the 
surrounding  structures.  I  found  the  stump  of  the  old  left 
lobe  which  had  been  removed,  and  proceeding  thence  I 
took  out  the  somewhat  enlarged  pyramidal  lobe  and  about 
half  of  the  enlarged  right  lobe.  I  assured  myself  by  this 
method  —  that  is,  by  slicing  laterally  the  right  lobe  —  that 
the  parathyroid  glandules  were  not  disturbed.  To  the  same 
end,  the  blood  vessels  were  seized  and  controlled  within 
the  substance  of  the  gland  itself.  The  operation  occupied 
about  thirty-five  minutes  and  was  extremely  tedious;  the 
patient  bore  it  well,  however;  her  pulse  rose  but  little,  and 
while  the  stitches  were  being  put  in  it  was  counted  at  112. 
While  she  was  recovering  from  the  anesthetic,  that  is,  fif- 
teen minutes  later,  her  pulse  had  sunk  to  100,  and  all 
promised   well. 

Every  reasonable  operative  precaution  had  been  taken 
to  avoid  increasing  the  hyperthyroidism.  In  spite  of  the 
dense  adhesions  about  the  gland,  that  organ  had  been  handled 


TOXEMIAS.  223 

very  little,  while  after  the  operation  abundant  drainage  was 
provided.  Even  so,  one  recalls  with  interest  Crile's  as- 
sertion, based  on  numerous  investigations  and  experiments, 
that  the  escape  of  thyroid  secretion  during  the  operation 
has  little  or  nothing  to  do  with  post-operative  hyperthy- 
roidism. 

Trouble  began  immediately  after  our  patient  was  put 
to  bed.  She  was  the  victim  of  an  intense  and  prolonged 
nausea,  vomiting  frequently  and  painfully  for  twelve  hours. 
She  awoke  to  consciousness  in  a  state  of  excessive  irrita- 
bility, throwing  herself  about  the  bed,  demanding  to  be 
taken  up,  crying  out  for  the  nurse  every  two  or  three  minutes, 
continually  asking  for  ease  from  her  discomfort,  a  discom- 
fort which  she  failed  to  describe;  her  apprehension  became 
painful  and  extreme,  her  agitation  seemed  almost  mani- 
acal, and  her  former  tranquillity  was  so  far  abolished  that 
she  complained  bitterly  and  continually  of  her  attendants 
and  of  the  nature  of  her  treatment.  She  bewailed  the  fact 
that  she  had  submitted  to  a  second  operation,  and  assured 
us  continually  that  she  was  about  to  die.  At  the  end  of 
twelve  hours  the  reasonably  slow  and  steady  pulse  had  risen 
irregularly  to  130  and  140  and  the  temperature  to  103°;  the 
heart's  action  became  embarrassed,  intermittent  and  ir- 
regular; a  rapid  cardiac  dilatation  supervened;  the  patient 
was  bathed  in  sweat;  her  exophthalmos  became  exaggerated 
in  appearance  and  her  misery  almost  indescribable.  In  other 
words,  here  was  presented  a  picture  of  extreme  and  grave 
thyroid  poisoning,  such  a  picture  as  one  sees  in  the  most 
advanced  cases  of  Graves'  disease  immediately  before  death ; 
indeed,  death  was  imminent  in  the  case  of  this  unfortunate 
patient. 

I  attempted  in  every  way  to  relieve  her  misery  by  the 
use  of  appropriate  drugs,  but  the  rapid  deterioration  of  her 
heart  seemed  to  render  them  ineffective;  opium  alone  gave 
her  some  slight  comfort. 

The  situation  was  such  as  we  used  commonly  to  encounter, 
after  operating  for  Graves'  disease  two  or  three  years  ago, 
before  the  present  effective  technic  had  been  devised. 

The  patient  sank  rapidly  under  her  accumulated  suffer- 


224  SURGICAL   PROBLEMS. 

ings   and   died   some   thirty-six   hours   after   the  operation. 
She  died  of  acute  hyperthyroidism. 

The  case  In  Its  development  and  in  its  early  features  was 
conspicuously  atypical,  and  although  during  that  interval 
between  the  first  and  second  operations  characteristic  symp- 
toms accumulated,  so  that  the  case  became  almost  classi- 
cal In  Its  appearance,  still  the  condition  at  no  time  was 
regarded  as  serious.  One  cannot  but  ask  oneself  what  would 
have  happened  had  no  operation  been  done.  In  spite  of  the 
futility  of  this  question,  one  cannot  but  feel  that  had  no  sec- 
ond operation  been  done  the  patient  must  have  continued 
on  the  edge  of  a  volcano,  and  that  at  any  time,  almost, 
some  slightest  excitement  or  stimulus  might  have  thrown 
her  into  a  state  of  advanced  hyperthyroidism  from  which 
she  could  not  have  been  rescued.  Looking  back  at  my  own 
relation  to  her  Illness,  that  Is,  during  the  last  two  months 
of  her  life,  and  at  the  course  followed,  I  believe  now  that 
I  should  not  have  dallied  with  drugs,  but  should  have  fol- 
lowed the  example  of  her  first  surgeon  and  operated  immedi- 
ately after  she  consulted  me. 


TOXEMIAS.  225 

Case  71.  Several  times  during  the  years  1908  and  1909 
I  was  consulted  by  a  physician  in  Lynn  regarding  Mrs.  J.  M. 
Brattle,  thirty-five  years  of  age,  whose  condition  troubled 
him  a  good  deal.  .  He  described  her  as  an  active,  hard-working 
woman,  who  did  her  own  housework  and  occasionally  per- 
formed the  duties  of  an  attendant  nurse.  In  1906  she  had 
appendicitis,  but  no  operation  was  done,  and  there  appeared  to 
have  been  no  recurrence.  Moreover,  her  bowels  were  now  reg- 
ular and  her  appetite  good.  When  I  was  first  consulted  she  had 
been  married  ten  years,  to  an  elderly  man,  a  janitor  and 
night  watchman,  whose  vocation  and  addiction  to  alcohol 
disturbed  her  peace  continually.  She  was  never  pregnant, 
but  had  frequent  painful  catamenla.  In  1905  Mrs.  Brattle 
first  noticed  that  her  neck  was  enlarging,  and  was  told 
that  she  was  suffering  from  tuberculous  adenitis.  She  was 
also  told  that  she  had  Hodgkln's  disease,  that  she  had  ele- 
phantiasis, that  she  had  abscesses  resulting  from  gum- 
boils, and  various  other  lesions.  As  the  swelling  occasioned 
her  little  trouble  and  no  alarming  symptoms  supervened, 
she  conceived  a  contempt  for  the  various  persons  who  made 
these  diagnoses,  until  she  fell  into  the  hands  of  my  friendly 
consultant.  During  the  few  years  before  I  saw  her  she  had 
grown  excessively  nervous.  Finally,  on  being  told  that  she 
had  a  goiter,  she  applied  for  treatment  to  a  large  munici- 
pal hospital  In  Boston.  There  she  was  put  on  tonic  doses 
of  hydrobromate  of  quinine,  with  a  marked  improvement 
of  her  symptoms  for  awhile ;  but  In  spite  of  the  fact  that  she 
persisted  In  her  treatment  and  attended  regularly  the  hos- 
pital clinic,  she  had  seen  no  Improvement  for  about  a  year. 
She  said  further  that  she  had  frequent  headaches,  distressing 
shortness  of  breath  on  exertion,  and  was  extremely  appre- 
hensive.^ 

Mrs.  Brattle  eventually  consulted  me  In  person  on  the 
26th  of  January,  1910.  She  was  a  well-developed,  sprightly 
looking  woman,  handsome,  ruddy  and  active,  and  ex- 
tremely intelligent.  Her  weight  was  one  hundred  and 
forty- two  pounds,  and  she  said  that  she  had  lost  forty 
pounds  during  the  preceding  year,  which  seemed  highly 
improbable.     The   heart   was   not   enlarged   and    there  was 


226  SURGICAL    PROBLEMS. 

no  endocarditis  apparent;  the  rate  was  104.  Her  eyes  were 
not  peculiar.  There  was  a  marked  fibrillary  tremor  of  the 
fingers  and  tongue,  and  a  moderate  enlargement  of  the  left 
lobe  of  the  thyroid,  which  was  about  the  size  of  a  small 
lemon,  movable  and  soft, —  presumably  hyperplasia  of  the 
thyroid  gland.  In  view  of  the  long  course  of  the  disease 
and  the  fact  that  she  had  already  experimented  with  ex- 
cellent medical  treatment,  I  advised  operation,  —  excision 
of  the  left  lobe  of  the  thyroid,  with  the  isthmus. 

I  saw  no  more  of  Mrs.  Brattle  for  a  month,  when  she 
reported  to  me  that  she  was  too  busy  to  take  out  time  for 
an  operation,  and  had  decided  to  go  on  as  she  was.^ 
Early  in  April,  however,  she  again  consulted  me,  and  said 
she  was  no  better  and  that  she  had  decided  to  have 
an  operation  done.  Accordingly,  she  entered  a  hospital, 
where  I  operated  on  the  12th  of  April.  The  dissection 
proved  to  be  rather  interesting.  In  the  left  lobe  of  the  thy- 
roid was  a  cyst  about  the  size  of  a  bantam's  egg,  with  very 
little  thyroid  tissue  about  it.^  The  left  lobe,  accordingly, 
was  removed,  except  for  a  small  amount  of  tissue  at  the 
upper  pole.  The  right  lobe  of  the  gland  was  found  to  be 
hyperplastic  and  about  twice  the  normal  size.  One  half 
of  this  lobe  was  removed  with  difficulty  and  with  a  consid- 
erable hemorrhage. 

The  operation  proved  successful  and  the  patient  has 
remained  well.  She  rallied  promptly  from  the  shock,  and  went 
home  at  the  end  of  two  weeks.  The  pulse  rate  returned  to 
80  in  the  course  of  [a  month,  and  has  remained  reasonably 
low.  Her  other  symptoms  gradually  disappeared,  and  as 
her  eyes  had  never  been  troublesome  she  now  seems  com- 
pletely well.'^ 

^The  reader  who  is  familiar  with  the  usual  symptoms 
of  Graves'  disease  will  have  little  difficulty  in  making  a 
proper  diagnosis  from  the  above  symptoms.  The  usual 
difficulty  in  diagnosticating  Graves'  disease  is  inability  to 
discover  the  cardinal  symptoms.  Physicians  should  remem- 
ber, however,  that  all  of  the  cardinal  symptoms,  especially 
the  classical  symptoms  exophthalmos,  goiter  and  tachy- 
cardia, are  not  always  present  together.     I  lay  great  stress 


TOXEMIAS.  227 

on  nervousness,  apprehension  and  tremor.  When  these 
are  associated  with  a  goiter,  especially  if  tachycardia  also 
develop,  one  should  name  the  group  of  symptoms  Graves' 
disease  without  further  question. 

2  This  sort  of  indecision  and  willingness  to  postpone  an 
operation  is  extremely  common  in  these  cases  of  Graves' 
disease.  For  one  reason,  the  patients  are  apprehensive, 
but  often  fail  to  recognize  the  gravity  of  their  own  con- 
dition. In  the  second  place,  we  are  not  yet  in  a  position 
to  promise  them  a  sure  cure  from  operation.  That  is  the 
weakness  of  the  surgical  position  at  present.  We  can  say 
that  between  seventy  and  eighty  per  cent  of  the  cases  oper- 
ated upon  seem  to  be  permanently  cured,  but  patients  ask 
for  something  better  than  that. 

^  This  cyst  represents  the  cystic  degeneration  of  a  hyper- 
plastic goiter,  with  which  the  pathologists  are  familiar. 
It  signifies  a  degeneration  of  the  gland.  If  this  were  all, 
one  would  expect  an  amelioration  in  the  symptoms  of  hy- 
perthyroidism; indeed,  that  amelioration  frequently  takes 
place.  Not  only  may  the  gland  so  far  degenerate  as  to  cease 
to  give  hyperthyroid  symptoms,  but  it  may  go  on  to  the 
point  of  great  destruction  of  gland  tissue,  so  that  the  reverse 
of  hyperthyroidism  is  established,  and  the  patient  becomes 
eventually  the  subject  of  a  myxedema.  These  are  the  cases 
described  as  dif^cult  by  Beebe  and  Rogers,  —  the  cases 
yielding  slowly,  if  at  all,  to  serum  therapy,  and  necessitat- 
ing medication  by  dessicated  thyroids  in  conjunction  with 
the  serum  therapy.  It  would  appear  that  the  prognosis 
in  these  cases  under  serum  and  thyroid  therapy  is  extremely 
doubtful. 

^  Be  it  remembered  that  the  eye  symptoms,  in  ordinary 
cases  of  Graves'  disease  operated  upon,  are  the  last  to 
disappear. 

[Dr.  William  F.  Whitney's  report  on  this  specimen 
is  not  uninteresting:  "The  specimen  consists  of  a  portion 
of  a  cystic  tumor  from  the  thyroid,  and  a  part  of  a  lobe 
from  the  other  side.  Microscopic  examination  of  the  cyst 
wall  showed  large,  dilated  follicles  filled  with  dense  eosin 
staining  colloid.  Examination  of  the  other  lobe  showed  a 
similar  condition,  but  without  any  signs  of  pressure.  Diag- 
nosis:  intra-alveolar  hypertrophy."] 


228  SURGICAL    PROBLEMS. 

Case  72.  The  following  case,  of  unusual  severity,  is  worth 
recording,  if  only  as  an  example  of  the  exigencies  of  prac- 
tice in  certain  alarming  toxemias. 

Miss  Annie  White  was  a  strong,  well  girl  up  to  the  age 
of  twenty-three,  devoted  to  social  life,  out-of-door  sports 
and  the  activities  of  blameless  gaiety.  She  had  had  no  ill- 
nesses and  was  without  serious  responsibility.  She  lived 
quietly  at  home  with  her  mother,  in  a  country  town  near 
Boston.  When  twenty-three  she  began  to  develop  symptoms 
of  neurasthenia;  she  became  nervous,  wakeful,  easily  tired  and 
lachrymose.  Accordingly,  for  neurasthenia  she  was  treated 
with  rest  cures  and  tonics.  At  the  end  of  a  year  she  was  no 
better.  Then  she  began  to  complain  of  eye  strain,  and 
her  physician  discovered  a  slight  exophthalmos  of  both  eyes. 
He  promptly  made  a  diagnosis  of  Graves'  disease,  and  put 
her  on  a  variety  of  treatment.  At  the  end  of  another  year 
her  symptoms  had  become  worse;  the  exophthalmos  had 
increased,  an  obvious  tumor  of  the  thyroid  gland  had  devel- 
oped, the  patient  was  more  fretful,  plagued  with  a  continual 
tremor  of  the  hands,  with  a  marked  tachycardia,  and  with 
loss  of  weight  and  strength.  She  was  then  taken  to  consult 
a  Boston  neurologist,  by  whose  advice,  and  very  properly, 
she  was  put  under  the  serum  treatment  of  Beebe  and  Rogers. 
After  nine  months  of  such  treatment,  without  benefit,  her 
condition  had  become  deplorable.  At  that  time,  on  the 
17th  of  May,  1910,  she  entered  the  Massachusetts  General 
Hospital  under  my  care. 

In  addition  to  the  symptoms  already  noted,  I  found 
that  she  was  constantly  bathed  in  a  profuse  perspiration, 
was  flushed,  was  the  victim  of  an  obstinate  diarrhea,  and  was 
continually  weeping.  She  wept  when  she  was  spoken  to; 
she  wept  when  she  was  left  alone.  She  wandered  aimlessly 
up  and  down  the  hospital  corridor,  crying  to  be  taken  home, 
and  conducting  herself  much  as  a  forlorn  and  abandoned 
child.  At  the  same  time  she  was  so  weak  that  she  tottered, 
while  her  appetite  was  nil  and  her  nutrition  bad.  I  regarded 
her  as  a  desperate  and  difficult  case.  She  was  put  to  bed 
for  a  week,  was  given  large  doses  of  hydrobromate  of  quinine, 
and  sleep  was  induced  by  additional  bromides.    She  was  kept 


TOXEMIAS.  229 

quiet  and  isolated,  with  a  special  nurse.  At  the  end  of  this 
time  her  pulse,  which  had  been  140,  had  come  down  to  115, 
and  she  appeared  somewhat  more  cheerful.  During  this 
week  I  carried  on  the  system  of  fictitious  inhalations,  pre- 
paratory to  an  operation. 

On  the  24th  of  May  I  performed  a  preliminary  double 
ligation  of  the  superior  thyroid  arteries.^  Miss  White  was 
helped  by  this  operation,  supplemented  by  rest  and  hospital 
care.  Her  agitation  became  much  less,  her  sweating  de- 
creased, her  pulse-rate  fell  to  100  and  her  courage  was  re- 
newed. We  explained  to  her  and  to  her  mother  the  nature 
of  what  had  been  done  and  the  probability  of  having  to  do 
something  further,  but,  with  our  consent,  she  was  taken 
home  to  continue  her  rest  cure,  and  to  recuperate  if  possible. 
On  the  17th  of  August,  and  with  the  advice  of  her  phy- 
sician, Miss  White  consulted  me  again  at  my  ofhce.  She 
looked  slightly  heavier  and  appeared  more  self-reliant 
than  when  she  left  the  hospital,  but  the  exophthalmos  was 
still  present,  with  associated  lagging  of  the  lids.  She  was 
flushed  and  anxious,  there  was  a  strong  bruit  over  both 
lobes  of  the  thyroid,  which  were  enlarged  to  about  the  size 
of  a  hen's  egg  each;  the  heart  was  pounding  and  rapid, 
at  the  rate  of  132;  while  there  was  a  very  marked  fibrillary 
tremor  of  the  fingers  of  both  hands.  Nevertheless,  the  con- 
dition was  distinctly  better  than  when  I  first  saw  her,  three 
months  earlier,  and  I  felt  that  an  operation  was  justified, 
although  the  risk  was  extremely  great.  Her  family  recognized 
the  situation,  and  authorized  me  to  proceed  at  any  risk.^ 

On  the  24th  of  August,  after  the  usual  careful  preparation 
and  an  endeavor  to  bring  the  patient  to  the  ordeal  in  a 
placid  condition,  I  proceeded  with  the  operation.  Here  are 
the  notes  from  my  record:  "The  patient  was  brought  to 
the  operation  in  excellent  psychic  condition,  without  any 
true  appreciation  of  the  undertaking.  Her  pulse  was  120, 
temperature  100°.  The  anesthetic  used  was  nitrous  oxide  and 
oxygen  with  occasionally  a  little  ether.  The  operation  lasted 
about  forty  minutes,  and  the  patient's  strength  failed  steadily 
throughout  the  procedure.  At  the  end  she  had  no  pulse 
at  the  wrist,  while  the  tripping  cardiac  apex  registered  190. 


230  SURGICAL    PROBLEMS. 

Through   the   usual   transverse  incision   the  right  lobe  was 
delivered   by   stripping   the   posterior   capsule.      There   was 
very  slight  hemorrhage.     The  isthmus  was  then  dissected 
out,  with  a  good  deal  of  hemorrhage;  and  half  of  the  left 
lobe    was    excised,    again    with    considerable    hemorrhage, 
controlled  with  great  difficulty.    The  total  amount  of  hemor- 
rhage, however,  was  not  excessive,  and  it  was  evident  that 
the  patient's  collapse  was  due  to  the  shock  of  the  operation. 
The  wound  was  closed  hastily,  being  partially  packed  with 
gauze,  owing  to  the  emergency  of  the  situation.    When  back  in 
bed  her  pulse  at  the  wrist  returned,  and  six  hours  later  had 
fallen  to  i6o,  of  fair  quality.    Her  temperature  was  then  ioi°." 
Miss  White's   convalescence  was  extremely  stormy,   and 
illustrates    the    desperate    condition    which    these    patients 
may  reach.    The  day  after  her  operation  was  a  bad  day  for 
her;   the  morning  temperature,  starting  with  99°,  rose  gradu- 
ally  to    105°   during    the    day;    the   pulse   became   dicrotic 
and  irregular,  varying  from  130  to  180;  she  looked  badly, 
was  irrational  and  evidently  in  a  condition  of  pronounced 
toxemia.     I  gave  to  her  friends  a  bad  prognosis.     On  the 
next  day  the  toxemia  was  worse,  the  temperature  reached 
105.6°,  the  pulse  varied    from   150  to  170,  and  the  respira- 
tions rose  to  40.     Notwithstanding  the  desperate  outlook, 
I  still  had  some  hope,  because  she  was  able  to  take  nourish- 
ment, passed  a  reasonable  amount  of  urine  and  had  several 
large   movements   of   the   bowels.      The  drainage   from   the 
wound  was  profuse.     On  the  third  day  after  the  operation, 
and  within  a  space  of  three  hours,  the  patient  improved  so 
suddenly  and  rapidly  that  she  was  soon  out  of  danger.    The 
temperature  fell  to  100°,  the  pulse  to  120,   the  respirations 
to  26,  while  her  mental  condition  improved  greatly  and,  from 
being  almost  in  a  state  of  coma,  she  became  bright,  interested 
and  intelligent.^ 

^  Ligation  of  the  superior  thyroid  arteries  can  usually 
be  done  under  cocaine,  and  is  an  extremely  simple  and 
efficient  step  in  the  treatment  of  goiter.  I  regard  it  rarely 
as  curative.  I  employ  it  in  mild  cases  and  in  desperate  cases ; 
in  the  mild  cases  with  the  hope  that  the  decreased  blood 
supply  will  tend  to  check  the  progress  of  the  disease ;  in  the 


TOXEMIAS.  231 

desperate  cases  merely  with  the  hope  of  ameliorating  the  symp- 
toms and  progress  of  the  disease,  so  that  subsequently 
a  more  radical  operation  may  be  performed. 

-  The  situation  I  have  described  is  one  of  the  most  trying 
to  which  a  surgeon  can  be  subjected.  He  knows  that  he 
undertakes  so  desperate  an  operation  with  a  more  than  even 
chance  that  the  patient  will  not  survive.  He  knows,  at  the 
same  time,  that  without  an  operation  the  patient  can  live 
but  a  short  time.  If  he  is  experienced,  he  knows  also  that 
in  spite  of  his  explanations  the  death  of  the  patient  after 
the  operation  will  be  surely  set  down  to  his  discredit  in  the 
minds  of  the  friends  of  the  victim. 

^  Pathologist's  report:  "  A  whole  lobe,  isthmus  and  por- 
tion of  the  other  lobe  of  a  thyroid.  The  complete  mass  is 
7  by  5  by  5  cm.  On  section  the  tissue  is  rather  cellular  and 
homogeneous  with  comparatively  little  colloid.  Micro- 
scopical examination  shows  a  very  marked  increase  in 
fibrous  tissue  between  the  lobules.  In  this  fibrous  tissue 
are  extremely  large  blood  vessels  and  few  lymph  spaces. 
Within  this  fibrous  tissue  bands  of  epithelium  found,  from 
the  acini,  seem  to  be  undergoing  degenerative  changes. 
The  cells  are  comparatively  few,  small  and  closely  packed. 
The  lumina  have  frequently  disappeared.  In  some  areas, 
however,  the  acini  are  much  dilated  and  show  some  colloid, 
but  the  epithelial  cells  lining  these  spaces  are  flattened  and 
inactive  in  appearance.  Some  of  the  vessels  in  the  fibrous 
tissue  bands  show  thrombosis.  In  a  few  areas,  however, 
this  picture  is  entirely  changed  and  the  fibrous  tissue  is  small 
in  amount,  the  acini  large,  with  considerable  colloid,  and 
the  cells  active  in  appearance.  In  these  areas  also  there  Is 
considerable  hyperplasia  of  the  epithelium.  The  specimen 
appears  to  be  one  in  which  the  gland  Is  actively  functioning 
in  only  a  few  areas.  Most  of  it  is  given  over  to  sclerotic 
and  degenerative  changes.     Goiter." 

Miss  White  made  an  excellent  operative  recovery,  and 
left  the  hospital  two  weeks  after  the  operation.  Two  months 
later  she  reported  in  person  to  me.  The  improvement  in 
her  condition  was  striking.  Her  eyes  were  less  prominent, 
the  pulse  ranged  between  85  and  90,  tremor  was  slight, 
apprehension  had  gone.  She  appeared  happy  and  rosy, 
was  extremely  cheerful  and  loquacious,  and  announced  a 
gain  of  twenty-three  pounds.  At  this  writing  she  continues 
to  improve,  and  appears  now  as  a  robust,  active  girl. 


CHRONIC  INDIGESTION. 

Case  73.  Daniel  Saunderson  was  a  man  of  twenty- 
eight,  a  farmer,  who  consulted  me  on  the  advice  of  his  physi- 
cian in  1904.  He  was  sound,  active  and  well  nourished  in 
appearance.  For  some  five  years  his  friends  had  noticed 
that  his  disposition  was  changing.  Previously  cheerful, 
acute,  optimistic,  he  had  become  silent,  retiring,  morose. 
He  never  complained  of  ill-health,  but  it  was  evident  that 
he  was  suffering  from  a  mental  or  physical  ailment.  Oc- 
casionally he  would  go  all  day  without  food,  and  he  was  heard 
walking  the  floor  at  night.  In  the  summer  of  1904,  he  con- 
sulted me,  and  reluctantly  stated  that  he  had  long  suffered 
from  a  confirmed  dyspepsia.  He  was  constantly  depressed 
and  rendered  miserable  by  trifles.  His  surroundings  and 
daily  companions  had  become  irksome  and  intolerable  to 
him,  his  food  frequently  distressed  him,  he  was  greatly 
troubled  with  eructations  and  constipation,  and  three  days 
before  he  had  spent  a  wakeful  night  from  annoying  general 
abdominal  pain. 

I  had  known  the  man  for  several  years,  and  recognized 
the  mental  condition  which  he  described.  A  routine  ex- 
amination revealed  nothing  except  a  rather  marked  abdomi- 
nal distention,  until  I  came  to  the  right  iliac  fossa,  where 
on  deep  palpation  I  was  able  to  detect  an  apparently  irritable 
appendix,  which  was  quite  tender  on  pressure.  After  watch- 
ing the  case  for  a  couple  of  weeks,  and  finding  always  the 
tender  appendix,  I  advised  its  removal.  On  opening  the 
abdomen  nothing  abnormal  was  discovered  except  an  in- 
durated appendix,  slightly  swollen  and  adherent  throughout 
its  length  to  the  lateral  aspect  of  the  cecum.  The  patholo- 
gist reported,  "  The  appendix  was  seven  centimeters  long, 
of  somewhat  enlarged  diameter,  with  many  adhesions 
throughout  its  length;  upon  opening,  the  lumen  was  found 
to  be  obliterated  at  one  end,  dilated  beyond,  and  containing 
thick,  glairy  mucus;  obliterating  appendicitis." 

233 


234  SURGICAL    PROBLEMS. 

The  convalescence  was  uneventful.  The  patient  was  out 
of  bed  on  the  twelfth  day  and  went  home  at  the  end  of  two 
weeks.  His  dyspeptic  symptoms  disappeared,  and  the  ac- 
tion of  his  bowels  became  normal.  The  most  striking  change 
was  in  his  mental  attitude.  Two  months  after  the  operation 
he  had  regained  his  natural  cheerfulness,  and  his  friends 
reported  that  the  "  blues  "  had  been  banished. 


CHRONIC   INDIGESTION.  235 

Case  74.  Madam  Bauer,  a  German  lady  of  sixty-eight, 
speaking  rather  broken  English,  had  lived  in  this  country 
some  three  years  when  she  consulted  me,  on  the  31st  of  De- 
cember, 1905.  She  was  a  widow,  and  had  one  daughter 
living,  a  middle-aged  woman.  Madam  Bauer  was  a  Vien- 
nese by  birth,  with  all  the  excitability  and  simplicity  of  the 
home-loving  Austrian.  For  twenty-five  years  she  had  suf- 
fered more  or  less  from  dyspepsia,  with  occasional  attacks 
of  bloating  and  chronic  constipation;  rarely  nausea  and 
vomiting  after  a  hearty  meal,  with  a  proclivity  for  Bavarian 
beer  and  a  tendency  to  corpulence.  When  I  was  called  to 
see  her  I  found  her  in  bed,  but  comfortable,  and  telling  the 
story  that  she  had  had  a  bad  stomach  ache  all  night,  but  that 
the  disturbance  was  relieved  by  a  movement  of  the  bowels 
in  the  morning.  She  was  cheerful,  ruddy  and  loquacious, 
but  was  said  to  be  extremely  despondent  about  her  health, 
owing  to  her  age  and  a  suspected  heart  disease. 

I  found  her  heart  slightly  hypertrophled,  with  an  unimpor- 
tant mitral  systolic  murmur.  Her  chest  was  otherwise  nega- 
tive, her  abdomen  full  and  tympanitic,  but  soft  and  nowhere 
particularly  tender  except  In  the  umbilical  region.^ 

I  put  the  patient  on  a  carefully  restricted  diet  and  kept 
her  in  bed  for  a  few  days,  when  she  said  that  she  felt  prac- 
tically well  and  wished  to  get  up.  There  was  still  some  sore- 
ness In  the  abdomen,  however,  slightly  to  the  right  of  the 
navel,  and  a  sense  of  great  prostration  when  she  stood. 

Two  weeks  after  my  first  Interview  with  her  she  suffered 
a  slight  relapse,  the  pain  to  the  right  of  the  umbilical  region 
returning,  with  a  mild  run  of  fever,  reaching  100°  In  the 
evening.  The  next  day  she  was  active.  Three  or  four  days 
later  she  said  that  she  felt  perfectly  comfortable,  but  was 
growing  weaker.  I  could  discover  no  obvious  abnormality. 
She  took  nourishment  well,  but  on  slight  exertion  vomited. 
Her  bowels  moved  daily  and  freely,  without  pain.  On  the 
l6th  of  January,  seventeen  days  after  my  first  visit,  all  ten- 
derness had  greatly  diminished,  though  the  nausea  and 
vomiting  on  slight  exertion  persisted.  She  subsisted  on  a 
liquid  diet.  At  this  time  I  made  a  further  and  more  careful 
examination  of  the  abdomen,  which   I  was  enabled  to  do, 


236  SURGICAL   PROBLEMS. 

as  pain  and  tenderness  had  practically  disappeared.  I  now 
found  for  the  first  time  a  mass  the  size  of  a  pigeon's  egg  in 
the  region  of  the  cecum.  It  was  movable,  tender,  firm 
and  slightly  nodular.  I  was  obliged  to  reverse  my  former 
optimistic  prognosis,  and  inform  the  patient's  family  that 
she  probably  had  a  malignant  disease  of  the  intestine.  At 
the  request  of  the  family,  I  called  in  consultation  a  well- 
known  internist,  who  saw  the  patient  twice  in  the  course 
of  a  week.  He  found  the  right-sided  mass  which  I  have  de- 
scribed, and  after  his  first  visit  was  reasonably  confident 
that  it  was  malignant.  He  suggested  the  employment  of 
high  oil  enemata,  in  order  to  clear  the  colon.  On  his  second 
visit  he  found  the  mass  again.  It  seemed  to  him  somewhat 
larger  than  before,  and  he  asserted  that  he  could  detect 
metastatic  masses  in  the  liver  and  omentum.  He  was  then 
positive  that  we  were  dealing  with  malignant  disease.  Dis- 
satisfied with  this  opinion,  the  family  then  named  and  asked 
me  to  call  another  consultant,  a  man  in  whom  I  had  every 
confidence.  My  second  consultant  made  a  careful  examina- 
tion of  the  stools,  and,  as  he  was  unable  to  detect  occult 
blood,  stated  that  he  doubted  the  diagnosis  of  malignancy 
and  suggested  that  we  were  dealing  with  a  chronic  appendi- 
citis. 

The  facts  of  the  case  were  laid  before  the  patient  and  her 
friends,  the  uncertainty  of  the  diagnosis  was  asserted,  and 
an  exploratory  operation  was  advised.  To  this,  after  much 
delay,  they  consented.^ 

^  While  the  sort  of  history  that  I  have  given  of  the  physi- 
cal examination  suggests  the  possibility  of  chronic  appendi- 
citis,   one   must   not   forget   that   malignant   disease   of   the 
intestines  is  to  be   regarded  as  probable  in  a  person  sixty- 
eight  years  of  age,  and  appendicitis  less  probable. 

^  I  am  convinced  that  the  resource  of  exploration  is  turned 
to  with  lamentable  infrequency.  A  considerable  experience 
with  obscure  disease  of  the  abdomen  has  shown  me  that 
great  numbers  of  cases  are  proven  harmless  in  which,  without 
the  exploration,  a  fatal  prognosis  would  have  been  given, 
and  the  patient  doomed  to  a  long  course  of  misery  and 
anxiety.  Exploratory  section  should  be  made  through  a 
small   incision,   when,   if  no   further  operation   is  done   the 


CHRONIC    INDIGESTION.  237 

incision  can  be  closed  firmly  and  the  patient  gotten  out  of 
bed  within  three  or  four  days. 

On  the  13th  of  February,  some  six  weeks  after  my  first 
visit,  I  operated  on  Madam  Bauer,  and  explored  thoroughly 
the  abdomen.  The  abdominal  wall  was  very  fat,  and  I 
found  unusual  masses  of  fat  in  the  mesentery,  but  no  sign 
of  malignant  metastasis  was  there.  These  masses  doubt- 
less were  those  supposed  tumors  felt  by  my  first  consultant. 
The  gall  bladder  was  somewhat  distended,  but  there  was  no 
growth  in  the  liver,  nor  was  the  liver  enlarged.  The  uterus 
w^as  senile,  very  high  and  movable,  with  its  fundus  lying  in 
the  neighborhood  of  the  cecum.  It  was  about  half  the  size 
of  a  closed  fist,  round  and  hard,  suggesting  a  solid  tumor 
of  some  sort.  Close  to  the  fundus  of  the  uterus  lay  the  ap- 
pendix, injected,  adherent  to  the  mesentery,  and  the  obvious 
source  of  the  patient's  symptoms.  The  tumor  which  we  had 
felt  was  undoubtedly  the  fundus  of  the  uterus. 

The  adnexa  were  not  abnormal,  and  we  found  no  tumor 
of  the  intestines.  I  therefore  made  a  diagnosis  of  small 
myoma  of  the  uterus,  w4th  chronic,  obliterative  appendicitis. 
I  removed  the  appendix  and  closed  tightly  the  abdominal 
wound.  The  patient  recovered  promptly  from  her  ether, 
and  went  on  to  an  excellent  recovery,  leaving  the  hospital 
at  the  end  of  a  month.  I  have  heard  from  her  several  times 
in  the  course  of  the  last  five  years,  and  learn  that  she  is  in 
excellent  health  and  has  had  no  recurrence  of  her  bad 
symptoms. 

This  case  illustrates  one  of  the  many  obscure  abdomi- 
nal disturbances  for  which  a  chronic  appendicitis  may  be 
mistaken. 


238  SURGICAL    PROBLEMS. 

Case  75.  The  subject  of  this  problem  was  a  happily 
married  woman  of  thirty-five,  the  wife  of  a  schoolmaster, 
living  in  the  suburbs  of  Boston,  Mrs.  M.  W.  Theodore. 
She  was  the  mother  of  two  vigorous  boys,  ten  and  twelve 
years  of  age.  I  was  asked  to  see  her  in  consultation  in 
October,  1906.  The  only  important  feature  of  her  previous 
history  lay  in  the  statement  that  she  had  been  for  a  long 
time  the  victim  of  a  pronounced  uterine  displacement, 
which  was  corrected  by  a  pessary.  She  had  regarded  her- 
self as  well  until  within  four  weeks,  when  she  was  suddenly 
seized  with  acute  pain  and  tenderness  in  the  right  metatarsal 
region,  with  a  sudden  rise  of  temperature  to  103°.  She 
was  treated  by  her  family  physician  and  by  a  competent 
orthopedic  surgeon  for  acute  flat-foot,  but  the  pain  persisted. 
In  the  course  of  two  weeks  her  shoulders,  elbows  and  left 
ankle  had  become  involved  in  the  pain,  and  she  developed 
an  acute  multiple  arthritis,  without  any  obvious  source  of 
infection.  The  disease  ran  on,  with  little  abatement,  up 
to  the  time  when  I  saw  her,  with  pain,  fever  and  wasting. 
On  the  morning  of  my  visit  Mrs.  Theodore  informed  me 
that  she  felt  nearly  free  from  pain,  for  the  first  time.  Her 
temperature  was  then  102°.  However,  she  asserted  that 
she  was  better,  and  she  was  said  to  look  better.  I  learned 
that  on  the  day  previous  she  had  had  a  leukocyte  count  of 
27,000. 

I  found  the  patient  to  be  a  tired,  middle-aged  appearing 
woman,  seeming  somewhat  older  than  her  years,  hectic, 
argumentative,  highly  intelligent,  emaciated.  There  was 
nothing  in  the  throat  to  account  for  her  condition. ^  Her 
heart  and  lungs  were  not  abnormal,  nor  were  the  kidneys. 
My  careful  physical  examination  revealed  at  first  nothing 
peculiar  beyond  a  slight  grating  in  the  right  metatarsal 
joints.  The  abdomen  was  flat  though  the  colonic  tympany 
was  somewhat  low.^  The  uterus  was  retrocessed,  sagging 
feebly  in  the  pelvis,  and  about  the  size  of  a  closed  fist.  Rec- 
tal examination  revealed  a  tight  sphincter  and  a  collapsed 
rectal  ampulla.  The  patient  did  not  look  very  ill.  It  seemed 
to  me  at  that  time  that  she  was  probably  beginning  to  mend, 
and  that  general  treatment  alone  was  indicated.     I  advised 


CHRONIC    INDIGESTION.  239 

therefore,  open  air,  sunlight,  forced  feeding,  abundance  of 
water  drinking  and  nux  vomica,  and  gave  a  good  prognosis. 
In  the  course  of  two  months  she  recovered  her  usual  health, 
which  was  not  very  vigorous. 

One  year  later  I  saw  Mrs.  Theodore  again  with  her  physi- 
cian. She  informed  me  that  since  her  convalescence  of  the 
year  before  she  had  had  a  troublesome  dyspepsia,  with 
occasional  heartburn  and  eructations  of  gas  after  eating. 
At  the  time  of  this  visit  she  had  been  in  bed  for  five  days, 
with  slight  nagging  pains  in  the  cecal  region,  with  obstinate 
constipation,  slight  nausea,  and  a  temperature  ranging  from 
99°  to  101°,  pulse  from  90  to  100.  She  thought,  but  was  not 
sure,  that  this  was  the  third  similar  attack  that  she  had  had 
within  five  years.  Menstruation,  which  had  begun  that 
morning,  appeared  to  bring  with  it  relief  from  pain.  Her 
leukocyte  count  was  18,000.  I  made  a  diagnosis  of  recur- 
ring appendicitis,  and  advised  an  operation  in  the  interval 
between  attacks.^ 

Three  months  later,  on  the  loth  of  February,  1908,  I 
operated  on  this  patient.  Since  my  last  interview  with  her 
she  had  been  feeble,  with  occasional  right  pelvic  pains  and 
loss  of  appetite,  though  there  had  been  no  distinct  attack 
of  appendicitis.  I  opened  her  abdomen  through  the  low 
McBurney  incision.^ 

^  As  is  well  known,  infected  tonsils  are  a  common  source 
of  a  toxemia  which  may  attack  several  joints. 

2  Low  colonic  tympany  in  a  patient  bedridden  suggests 
the  possibility  of  enteroptosis,  with  possible  fecal  stasis 
as  a  source  of  infection. 

^  A  relapsing  or  chronic  appendicitis,  associated  with 
ptosis  and  recurring  attacks  of  arthritis,  is  an  extremely 
familiar  combination.  I  suspect  that  the  primary  condition 
is  the  ptosis,  which,  through  interference  with  the  blood 
supply  of  the  appendix,  keeps  that  organ  in  a  state  of  im- 
paired nutrition. 

'  The  low  McBurney  incision  is  too  little  used.  Its  ad- 
vantages are  these:  i.  It  is  low  in  the  abdomen,  starting 
half  an  inch  below  the  anterior  superior  spine  and  running 
parallel  to  Poupart's  ligament  for  about  three  inches.  2.  It 
exposes  the  abdominal  muscles  at  a  point  where  they  run 


240 


SURGICAL   PROBLEMS. 


more  nearly  parallel  than  higher  in  the  abdomen,  so  that 
splitting  them  widely  is  easy  and  secures  a  free  exposure 
of  the  bowel.  3.  At  this  point  the  caput  and  appendix 
are  usually  found,  the  appendix  often  popping  into  the  wound 
as  soon  as  the  peritoneum  is  opened.  4.  This  prominence 
of  the  appendix  renders  its  delivery  and  excision  extremely 
easy,  and  obviates  that  pulling  on  the  bowel  and  on  the 
mesentery  which  is  so  often  followed  by  temporary  paraly- 
sis and  stasis  during  convalescence.  5.  The  closure  of  the 
wound  is  easy  and  satisfactory. 

The  appendix  was  adherent  to  the  cecum;  it  was  kinked 
and  thickened.  I  removed  it.  The  uterus,  now  about  the 
size  of  two  fists, —  distinctly  larger  than  I  had  made  out 
before, —  was  of  symmetrical  shape,  somewhat  boggy,  and 
contained  an  intramural  myoma.  On  the  right  side  of  the 
pelvis  was  a  tubo-ovarian  cyst,  the  size  of  a  bantam's  egg, 
with  signs  of  old  inflammation. 

The  condition  of  the  uterus  presented  a  new  problem, 
such  as  a  surgeon  discovers  not  infrequently  at  operation. 
Should  I  remove  it,  or  should  I  not?  The  patient  had  not 
been  warned  of  a  possible  hysterectomy.  I  therefore  consulted 
with  her  husband,  who  was  certain  that  she  would  not  wish 
the  uterus  removed.  I  agreed  with  him  that  it  would  be 
reasonably  safe  to  leave  it  untouched.  The  patient  was 
approaching  the  end  of  the  child-bearing  period,  the  uterus 
had  given  her  no  trouble  for  many  years,  and  it  was  safe 
to  assume  that  it  might  be  left  without  great  risk  of  future 
trouble.  Accordingly,  I  removed  the  tubo-ovarian  cyst 
only,  secured  the  uterus  high  in  the  abdomen  by  ventro- 
suspension  and  closed  the  abdominal  wound.  All  this  was 
done  through  the  low  McBurney  incision,  which  can  be 
easily  enlarged  and  the  right  rectus  muscle  pulled  inward, 
so  as  to  provide  a  surprisingly  wide  field  in  which  to  work. 

Mrs.  Theodore  rallied  well.  Two  days  after  the  operation, 
however,  she  had  a  distressing  attack  of  tachycardia,  with 
sweating  and  tremor.  At  the  same  time  it  seemed  as  though 
there  were  a  suspicious  enlargement  of  the  right  thyroid 
lobe.  These  symptoms  and  this  apparently  enlarged  thy- 
roid disappeared  entirely  after  two  days.     She  had  had  no 


CHRONIC   INDIGESTION.  24I 

sign  of  Graves'  disease  previously,  but  I  still  think  that  the 
condition  was  one  of  acute  and  quickly  subsiding  hyper- 
thyroidism. 

The  operation  did  everything  for  the  patient  that  we 
expected.  For  the  past  four  years  she  has  remained  in  ex- 
cellent health,  and  has  suffered  no  inconvenience  from  the 
uterus, —  catamenia  being  regular  and  the  flow  moderate, 
—  nor  has  tachycardia  recurred. 


•      "INDIGESTION." 

Case  76.  The  subject  of  this  history,  Sheffield  Urie,  was  a 
well-known  business  man  of  Worcester,  much  in  the  public 
eye,  and  his  state  of  health  was  a  matter  of  concern  to  great 
numbers  of  persons.  In  1908  he  was  forty-nine  years  old, 
and  was  a  tired  man.  He  had  always  been  conspicuous 
as  a  brilliant  writer  and  speaker  and  a  master  of  his  voca- 
tion, but  he  had  led  an  indiscreet  life.  Highly  intelligent, 
animated,  persuasive  and  often  dogmatic,  he  had  early  fallen 
into  the  habit  of  over-stimulating  with  alcohol,  and  he  smoked 
to  excess.  In  his  early  history  there  was  no  serious  illness 
to  record  except  a  frontal  sinus  disease,  from  which  he  suf- 
ferred  while  in  college.  This  was  cured  after  a  duration 
of  some  five  years.  As  he  approached  middle  age,  Mr.  Urie 
became  a  heavy  eater,  and  his  weight  increased  from 
140  to  210  pounds.  He  was  five  feet  ten  inches  in  height. 
For  some  years  prior  to  1908  I  had  seen  him  frequently  in 
a  friendly  way,  and  he  had  consulted  me  occasionally  and 
casually  about  his  condition.  He  was  subject  to  severe 
"  head-colds,"  to  frequent  attacks  of  bronchitis,  to  occa- 
sional headaches,  to  flushings  and  palpitations,  and  he  had 
become  extremely  excitable.  At  the  same  time,  he  suffered 
occasionally  from  flatulence  and  epigastric  distress,  usually 
as  a  result  of  overeating.  I  was  in  the  habit  of  telling  him 
that  his  mode  of  life  was  indiscreet,  and  that  he  should  con- 
fine himself  to  a  simple,  rigid  diet,  and  avoid  alcohol,  but 
he  was  unwilling  to  adopt  such  a  course.  At  the  same  time, 
I  was  never  able  to  discover  any  serious  organic  disturbance 
in  him.  About  the  year  1906  I  recommended  to  him  a  com- 
petent internist,  and  urged  strongly  that  he  consult  him 
frequently  about  his  health.  Mr.  Urie  did  so,  but  appar- 
ently  disregarded   the   professional   advice   given   him. 

Early  in  1908  Mr.  Urie  became  the  victim  of  severe  and 
prostrating  illness,  which  alarmed  his  friends  greatly  for 
many  weeks  and   brought  him   nearly  to   the  point  of  ex- 

243 


244  SURGICAL    PROBLEMS. 

tinction.  The  nature  of  this  illness  was  never  altogether 
clear,  even  to  the  physicians  who  saw  him  frequently  in  con- 
sultation. He  appeared  to  suffer  primarily  and  especially 
from  a  severe  general  neuritis,  with  excessive  pains  in  the 
legs,  back  and  arms,  associated  with  excruciating  headaches. 
He  frequently  became  delirious;  he  lost  weight  rapidly,  and 
in  the  course  of  three  weeks  of  confinement  to  bed  had  shrunk 
extremely.  A  subacute  nephritis  developed ;  sugar  was  found 
in  his  urine  to  the  amount  of  four  and  five  per  cent.  It  was 
apparent  that  he  was  suffering  from  some  severe  toxemia, 
though  the  exact  source  of  the  poisoning  was  not  apparent. 
His  heart  gave  out  and  became  much  dilated;  the  mitral 
valve  for  awhile  was  entirely  incompetent.  He  developed 
an  extensive  edema,  and  was  regarded  as  near  the  point  of 
death.  This  condition  continued  at  its  height  for  nearly 
six  weeks;  then  gradually  he  improved;  the  state  of  the  kid- 
neys was  no  longer  disturbing,  the  sugar  in  the  urine  shrank 
to  the  vanishing  point,  his  fever  disappeared,  and  for  many 
weeks  he  suffered  merely  from  exhaustion  and  neuralgic 
pains.  His  appetite  did  not  improve,  however,  and  long 
after  the  establishment  of  convalescence  he  tottered  about 
his  house  and  was  driven  feebly  in  a  carriage,  apparently 
a  wreck  of  his  former  vigorous  self. 

The  severe  illness  which  had  begun  in  February  was  acute 
up  to  the  1st  of  April,  while  from  that  date  until  the  1st 
of  July  he  remained  a  pronounced  invalid.  In  July  he  was 
so  far  improved  as  to  go  away  for  his  health.  He  took  a  camp 
in  northern  Maine,  and,  attended  by  a  competent  man 
nurse  and  masseur,  planned  to  spend  two  months,  at  least, 
in  that  favorable  locality.  Unexpectedly,  on  the  afternoon 
of  the  13th  of  August,  he  returned  to  his  home,  and  sum- 
moned his  physician,  who  sent  for  me.  I  reached  him  late 
that  evening  and  was  told  the  following  story:  One  week 
previously,  while  in  camp,  he  had  a  sudden  attack  of  violent 
vomiting,  with  painful  retchmg  and  considerable  abdominal 
pain,  following  three  days  of  vigorous  abdominal  massage, 
given  for  from  one  to  two  hours  daily.  For  the  next  six  days 
the  vomiting  was  not  repeated,  but  general  abdominal 
discomfort  continued,  with  a  slight  fever  and  extreme  pros- 


INDIGESTION.  245 

tration.  He  was  constipated,  and  was  plagued  by  an  inces- 
sant headache.  Alarmed  about  his  condition,  he  broke 
camp  and  came  home. 

I  found  Mr.  Urie  in  an  excited  state.  He  was  lying  propped 
up  in  bed,  extremely  flushed,  didactic  and  loquacious. 
Though  his  general  condition  appeared  fair,  he  was  much 
emaciated.  Examination  of  the  urine  showed  little  that 
was  significant  save  sugar,  —  two  per  cent.  The  heart  was 
acting  well,  was  properly  hypertrophied  and  with  good 
compensation,  although  the  mitral  leak  persisted.  The 
abdomen  was  slightly  distended  and  everywhere  tympanitic, 
the  lower  portion  tender,  —  tender  especially  just  above  the 
pubes,  where  I  could  feel  a  deep  mass  the  size  of  two  fists. 
He  was  not  rigid  and  there  was  no  muscular  spasm.  I  made 
a  diagnosis  of  acute  appendicitis,  with  abscess,  in  which 
diagnosis  my  consultant  concurred.^ 

In  spite  of  the  grave  complications  in  Mr.  Urie's  case, 
it  was  evident  that  an  operation  must  be  done  to  relieve  his 
present  distress;  otherwise,  it  was  obvious  that  he  would 
drift  rapidly  into  a  severe  toxemia,  from  which  it  was  unlikely 
that  he  could  rally,  considering  his  exhausted  state.  Ac- 
cordingly, the  next  morning  I  removed  him  to  a  hospital 
and  operated  as  rapidly  as  possible. 

The  nature  of  the  anesthetic  was  an  important  feature 
in  this  case.  I  decided  against  employing  ether  or  chloroform, 
but  was  fortunate  to  secure  an  anesthetist  who  gave  the 
patient  nitrous  oxide  and  oxygen  with  brilliant  success.^ 

I  opened  the  abdomen  immediately  above  the  pubes, 
by  a  short,  quick  incision,  and  found  the  mass  glued  to  the 
parietal  peritoneum,  with  the  peritoneal  cavity  strongly 
walled  off.  On  the  mass  being  opened,  three  or  four  ounces 
of  extremely  foul  pus  escaped,  and  a  disorganized  appendix 
appeared,  gangrenous  and  sloughing.  The  stump  of  the 
appendix  was  tied  off,  the  wound  quickly  drained,  three 
retaining  stitches  were  placed  and  the  patient  was  returned 
to  bed,  —  all  in  the  course  of  fifteen  minutes,  —  and  in  ex- 
cellent condition.  He  rallied  promptly  from  the  operation 
and  was  talking  rationally  before  reaching  his  room. 

In  the  course  of  the  operation,  and  while  the  patient  was 


246  SURGICAL   PROBLEMS. 

relaxed  with  the  anesthetic,  I  was  able  to  make  a  fairly 
satisfactory  examination  of  his  abdomen.  It  was  apparent 
at  once  that  his  stomach  was  greatly  enlarged  and  lay  low, 
below  the  navel,  while  the  colon  was  distended  and  loaded 
with  fluid  feces. ^ 

Mr.  Urie  rallied  well  from  the  operation  and  made  an  ex- 
cellent recovery.^  The  deeply  drained  wound  healed  slowly, 
of  course,  but  after  three  weeks  the  patient  was  able  to  go 
home,  and  the  wound  was  sound  in  the  course  of  two  months. 
In  spite  of  the  serious  ordeal  through  which  he  had  passed, 
this  patient  was  able  to  resume  his  work  by  the  first  of  the 
following  year,  and  is  now  reported  to  me  as  actively  engaged 
in  a  number  of  financial  enterprises.  He  wears  a  strongly 
supporting  abdominal  belt,  eats  moderately,  follows  the 
advice  of  his  physician,  and  promises  to  continue  for  many 
years  as  a  useful  citizen. 

^  The  problem  presented  to  us  was  an  extremely  grave 
one.  The  state  of  the  patient's  heart  was  not  especially 
favorable  for  operation,  but  the  more  serious  condition  of 
his  kidneys,  coupled  with  the  fact  that  he  was  suffering  from 
diabetes,  made  the  outcome  of  an  operation  questionable. 
The  operation  itself  doubtless  might  be  done  without  serious 
risk,  but  the  complicating  ill  effects  of  a  general  anesthetic 
promised  to  be  serious. 

2  The  conspicuous  advantage  of  nitrous  oxide  plus  oxygen 
over  ether  is  that  it  does  not  diminish  the  patient's  resist- 
ance as  does  ether,  that  it  does  not  impair  his  immunity, 
that  it  does  not  increase  the  damage  to  diseased  kidneys, 
and  that  with  its  cessation  the  patient  promptly  rallies, 
without  the  familiar  exhausting  nausea  and  prostration  of 
ether  anesthesia. 

^  The  condition  of  visceral  ptosis  which  I  have  described 
may  have  had  an  important  bearing  upon  the  patient's 
previous  illness.  An  enlarged  stomach,  frequently  associated 
with  gastro-mesenteric  ileus,  which  his  symptoms  had  sug- 
gested, together  with  a  colon  low-lying  and  ineffectively 
emptying  itself,  may  well  have  been  the  site  of  stored  up 
waste  and  the  seat  of  fermenting  material  such  as  we  know 
may  bring  about  a  general  toxemia,  resulting  in  arthritis, 
neuritis  and  the  involvement  of  various  vital  organs.  It 
is  not  surprising  that  such  a  condition  should  have  culminated 
in  an  acute  appendicitis. 


"  INDIGESTION.  247 

*  Mr.  Urie's  wound  healed  with  unusual  rapidity  for  a 
wound  so  foul  and  serious.  The  healing  was  stimulated  by 
the  use  of  proper  vaccines,  which  I  employ  habitually  and 
as  a  routine  in  the  convalescence  after  operations  for  acute 
appendicitis. 


248  SURGICAL   PROBLEMS. 

Case  77.  Edward  Taylor  belonged  to  that  indefinite 
group  of  individuals  whom  the  newspapers  class  as  "club- 
men." He  was  a  person  of  independent  means,  who  spent 
much  of  his  time  in  France  and  England,  hunting  and  playing 
tennis.  While  addicted  to  the  habitual  use  of  alcohol,  he 
was  by  no  means  a  wreck,  but  doubtless  his  habits  had 
lowered  permanently  his  resisting  powers.  To  complete 
the  picture,  he  informed  me  that  although  he  was  the  father 
of  two  enterprising  sons,  his  wife  was  rarely  able  to  live 
with  him. 

In  mid-June,  1907,  Mr.  Taylor,  then  forty-six  years  of 
age,  came  to  Boston  to  attend  the  college  graduation  of  his 
elder  son.  The  night  before  Class  Day  he  dined  well,  and 
retired  in  comfort  at  about  midnight.  An  hour  later  he  was 
seized  with  severe  stomach  ache,  and  telephoned  to  me  for 
help.  I  was  unable  to  go  to  him,  but  at  my  request 
Dr.  T.  F.  Harrington  saw  him,  and  found  him  in  the  third  hour 
of  an  attack  of  acute  general  abdominal  pain,  with  slight 
nausea,  his  bowels  having  moved  three  times  within  two  hours, 
as  the  result  of  large  doses  of  salts  and  calomel,  which  the 
patient  had  taken  on  his  own  initiative.^ 

Mr.  Taylor  became  more  comfortable  during  the  following 
day,  but  at  four  the  subsequent  morning  —  that  is  to  say, 
about  twenty-four  hours  from  the  onset  of  his  attack  —  he 
summoned  Dr.  Harrington  again,  who  found  him  in  great 
pain.  There  was  absolute  intestinal  obstruction  and  the 
condition  appeared  most  grave.  His  temperature  at  that 
time  was  99.6°,  his  pulse  86,  small  and  feeble.  The  patient 
was  hysterical  and  anxious,  realizing  the  gravity  of  his  con- 
dition and  demanding  immediate-  relief.  I  saw  him  with 
Dr.  Harrington  early  in  the  morning.  He  was  a  slight, 
energetic  man,  of  fair  intelligence,  keen-eyed  and  suspicious, 
anticipating  early  dissolution.  He  was  muscular  and  well 
developed.  His  thoracic  organs  were  in  good  condition. 
The  whole  abdomen  was  slightly  distended,  everywhere 
rigid,  the  right  rectus  in  spasm,  and  pain  and  exquisite 
tenderness  uniform  over  the  whole  lower  portion  of  the 
belly.  Pressure  over  the  usual  site  of  the  appendix 
elicited  little  extra  pain,  and  that,  such  as  it  was,  was  said 


INDIGESTION.  249 

to  shoot  across  to  the  sigmoid  region.  An  examination 
of  the  rectum  was  negative.^  The  patient  had  been  vomiting 
shortly  before  my  arrival,  but  his  vomiting  had  ceased. 
His  temperature. was  ioo°,  pulse  no. 

Here  was  a  case  obviously  of  some  acute  abdominal 
infection,  involving  extensively  the  peritoneum  and  threaten- 
ing the  most  serious  results.  Whatever  the  local  organ 
involved,  it  was  evident  that  the  disease  had  spread  diffusely 
far  from  its  original  location.  As  appendicitis  is  the  most 
common  of  the  acute  abdominal  inflammations,  I  made  a 
provisional  diagnosis  of  acute  appendicitis.^ 

At  eleven  o'clock  the  same  morning  I  operated  on 
Mr.  Taylor,  in  a  neighboring  hospital.  I  opened  the  abdo- 
men through  the  right  rectus  muscle,  an  incision  which  I  now 
rarely  use,  as  I  find  the  low  McBurney  to  be  almost  uniformly 
satisfactory.  On  the  incision  of  the  peritoneum,  there  was 
a  sharp  spurt  of  purulent  fluid,  of  which,  unfortunately, 
no  culture  was  taken.  The  intestines  were  found  every- 
where deeply  injected  and  bathed  in  the  same  foul  fluid; 
they  were  distended  and  paralyzed.  The  appendix  was  ad- 
herent to  the  cecum,  gangrenous  and  perforated.  We  re- 
moved it,  drained  the  abdomen  by  three  wicks,  —  one  to 
the  appendix,  one  to  the  bottom  of  the  pelvis  and  one  to 
the  right  flank,  —  and  returned  the  patient  to  bed,  where 
he  lay  in  a  state  of  collapse,  groaning  and  vomiting,  for 
many  hours.  He  was  placed  in  the  Fowler  position  and  proc- 
toclysis was  established.* 

Mr.  Taylor's  convalescence  was  stormy.  Rarely,  in  the 
case  of  a  surgical  patient  who  recovered,  have  I  passed  through 
so  arduous  and  trying  an  ordeal  as  I  experienced  in  the  case 
of  this  man.  His  agitation  and  terror  persisted  for  many  days. 
Although  I  established  two  nurses  and  a  competent  surgical 
assistant  at  his  bedside  day  and  night,  he  was  continually 
sending  for  me,  to  explain  the  most  trifling  symptoms. 
I  have  no  doubt  that  his  deplorable  psychic  state  contrib- 
uted greatly  to  the  gravity  of  his  convalescence.  Never 
have  I  known  a  more  unreasonable  or  preposterous  patient. 
In  spite  of  all  this,  however,  he  got  well,  and  in  the  usual  time. 
Two  weeks   after   the   operation   he   returned   to   his   hotel, 


250  SURGICAL    PROBLEMS. 

and   two  months  later  he  was  driving  his  automobile  and 
playing  tennis.^ 

^  Dosing  with  salts  and  calomel  is  a  highly  improper  meas- 
ure of  relief  for  severe  and  protracted  bellyache.  No  man  may 
say  that  the  attack  is  not  due  to  some  severe  obstructive 
disease,  —  volvulus,  mesenteric  thrombosis,  diverticulitis, 
pancreatitis,  and  above  all,  appendicitis.  Drastic  cathartics 
will  serve  only  to  increase  the  pain  and  danger  of  the 
patient.  In  spite  of  this  well-recognized  fact,  which  has 
been  preached  without  cessation  by  intelligent  surgeons  for 
more  than  twenty  years,  one  finds  continually  that  hurried 
general  practitioners,  even  to-day,  resort  often  to  salts  and 
calomel  in  their  treatment  of  the  early  stages  of  acute  in- 
flammatory abdominal  disease.  Such  treatment  is  far 
worse  than  the  giving  of  morphia.  If  the  pain  is  so  severe 
as  to  demand  relief,  morphia  had  best  be  given,  though  as 
a  rule  all  drugs  should  be  withheld,  if  possible,  until  a  posi- 
tive diagnosis  is  reached,  or  until  the  need  of  a  surgical 
operation  is  established. 

^  The  practitioner  should  make  it  an  invariable  rule  to 
examine  the  rectum  in  cases  of  abdominal  disease.  In 
cases  of  acute  infections,  especially,  the  rectal  examination 
often  gives  surprising  new  information,  detecting  tenderness, 
bulgings,  swellings,  and  tumors  even. 

^  Beware  of  confusing  acute  appendicitis  with  perforating 
duodenal  ulcer.  We  have  already  considered  this  matter 
in  connection  with  a  previous  case. 

^  Ever  since  J.  B.  Murphy  gave  us  his  method  of  rectal 
"  seepage,"  or  proctoclysis,  in  1903,  I  have  used  it  invari- 
ably in  all  cases  of  acute  abdominal  infections.  My  profes- 
sional readers  doubtless  understand  its  significance  and 
method  of  action.  The  slowly  dropping  stream  of  salt 
solution  introduced  into  the  rectum  is  quickly  absorbed  by 
the  bowel,  is  passed  on  to  the  lymphatics  of  the  peritoneum 
and  accumulates  freely  in  the  peritoneal  cavity.  The  Fowler 
position  (the  semi-upright  posture)  favors  the  collecting 
of  the  seepage  fluid  in  the  bottom  of  the  pelvis.  Thence 
this  fluid,  loaded  with  infecting  organisms  which  it  has 
collected,  is  drained  away  by  the  pelvic  drain.  In  the  case 
of  women,  I  frequently  lead  the  pelvic  drain  out  through 
the  vagina. 

^  We  are  often  asked  about  the  use  of  abdominal  supports 
after  these  operations  of  extensive  drainage  and  laceration 
of  the  abdominal  wall.     In  fact,  I  feel  that  in  these  cases 


"INDIGESTION."  25 1 

an  abdominal  support  is  essential,  although  I  never  use  one 
in  cases  of  operation  for  chronic  or  recurrent  appendicitis. 
After  operation  for  the  acute  suppurating  disease,  hernia 
must  be  expected.  It  occurs  in  at  least  one  third  of  the  cases. 
I  believe  that  a  support  discourages  the  formation  of  hernia. 


252  SURGICAL   PROBLEMS. 

Case  78.  The  intestinal  disorders  of  children  are  among 
the  difficult  problems  of  medicine, —  of  children,  especially, 
who  have  passed  the  need  for  infant  feeding  and  careful 
dieting.  There  are  more  elements  than  tuberculosis,  appendi- 
citis and  ptosis  in  the  problem. 

George  W.  Johnson,  when  ten  years  of  age,  was  brought 
to  me  in  something  of  an  emergency.  That  was  on  the 
30th  of  March,  1908.  His  mother,  an  extremely  intelli- 
gent woman,  told  me  a  long  story  of  his  early  years.  She 
said  that  he  had  always  been  slight,  delicate  and  under- 
developed; that  he  never  had  a  good  appetite;  that 
his  food  did  not  seem  to  nourish  him;  that  his  bowels  were 
irregular  and  that  the  movements  were  often  undigested. 
At  the  same  time,  she  assured  me  that  he  was  a  bright, 
intelligent  and  rather  precocious  child,  who  cared  little  for 
the  sports  of  other  children.  In  reply  to  my  questions, 
she  said  that  he  frequently  suffered  from  stomach  ache, 
and  appeared  to  have  wind  colics,  relieved  by  enemas  and 
by  vomiting.  One  month  before  I  saw  him  he  had  had  a 
frank,  acute  attack  of  appendicitis,  as  his  physician  testified, 
with  a  week  of  fever,  the  pulse  running  up  to  120;  tenderness, 
rigidity  and  spasm  low  on  the  right  side  of  the  abdomen, 
and  some  vomiting.  He  recovered,  however,  without  spe- 
cial treatment,  and  now  looked  forward  to  an  "  interval 
operation."  For  the  past  two  weeks  his  temperature  had 
been  normal,  but  he  had  been  very  feeble. 

I  found  George  Johnson  to  be  all  and  more  than  his  mother 
described;  a  bright-eyed,  alert,  precocious  child,  asking 
impossible  questions  and  keenly  interested  in  his  own  case, 
but  without  the  slightest  fear  of  an  operation  or  the  out- 
come of  treatment.  He  was  short  for  his  years,  slender,  sal- 
low and  emaciated,  with  what  we  are  accustomed  to  call 
a  tuberculous  appearance.  His  temperature  on  the  day  of 
his  visit  to  me  was  100°.  He  was  tender  over  the  usual 
site  of  the  appendix,  but  there  were  no  other  signs  or  symp- 
toms about  him  upon  which  I  could  lay  any  special  stress. 
I  sent  him  to  a  hospital  and  had  tuberculin  tests  made, 
but  they  were  negative.  On  the  next  day  he  was  more  ill, 
prostrate,    apathetic,    and    with    an    evening    temperature 


"  INDIGESTION."  253 

of  102°,  while  the  abdominal  tenderness  had  increased. 
On  going  over  the  abdomen  again,  however,  I  found  no  spe- 
cial distention,  spasm  or  rigidity,  nor  could  I  discover  a  mass 
in  the  appendix  region.  Two  days  later,  while  the  physical 
examination  remained  the  same,  his  temperature  was  running 
high,  with  an  excursion  suggesting  suppuration,  and  rang- 
ing from  99°  in  the  morning  to  103°  in  the  evening.  Dr. 
James  M.  Jackson  saw  the  boy  in  consultation  with  me,  but 
we  were  unable  to  decide  upon  any  diagnosis  beyond 
the  presumable  one  of  appendicitis.  Two  Widal  tests  were 
negative.  On  the  next  day  I  could  make  out  an  obscure 
mass  below  the  liver,  a  mass  which  in  an  older  person  would 
have  suggested  a  malignant  disease  of  the  colon. 

The  condition  was  apparently  becoming  desperate,  and 
my  consultant  agreed  with  me  that  a  hasty  exploratory 
operation  was  justifiable.  We  had  taken  the  blood  for  a 
third  Widal  test  that  morning,  but  had  not  yet  received  a 
report.  About  four  o'clock  in  the  afternoon  of  April  3 
I  opened  the  abdomen,  through  the  right  rectus,  on  a  level 
with  the  umbilicus.  I  found  the  intestines  normal  in  appear- 
ance, and  a  long,  adherent,  kinked  and  slightly  thickened 
appendix,  which  I  removed.  There  were  considerable 
bunches  of  large  lymph-nodes  scattered  through  the 
mesentery,  firm,  smooth  and  not  broken  down.  I  removed 
one  node  for  examination.^  The  abdominal  wound  was  then 
closed  quickly  and  the  child  put  back  to  bed.  He  had  re- 
ceived a  minimum  of  ether  and  rallied  promptly,  apparently 
none  the  worse  for  his  experience.  That  evening,  two  hours 
after  the  operation,  I  received  a  third  written  report  from  the 
Board  of  Health,  stating  that  there  was  a  positive  Widal 
reaction  in  the  case.  This  complication  is  not  surprising, 
but  it  is  a  complication  which  must  constantly  be  borne  in 
mind  when  considering  appendicitis.^ 

^  The  investigation  of  the  abdomen  up  to  this  point  sug- 
gests three  things:  First,  an  appendicitis,  for,  in  spite  of 
the  fact  that  the  appendix  appeared  negative,  experience 
teaches  that  a  very  slightly  diseased  appendix  may  set  up 
a  severe  train  of  symptoms  in  a  child.  Second,  the  enlarged 
nodes,  with  the  child's  general  appearance  and  chronically 


254  SURGICAL   PROBLEMS. 

poor  condition,  suggest  the  possibility  of  tuberculosis. 
It  was  for  this  reason  that  I  removed  a  node  for  examination. 
Third,  the  condition  might  well  be  typhoid  fever.  There 
were  no  rose  spots  and  no  enlargement  of  the  spleen,  nor  were 
the  stools  characteristic, —  indeed,  the  child  was  chronically 
constipated, —  still,  typhoid  fever  had  to  be  regarded  as 
possible. 

2  Appendicitis  may  co-exist  with  typhoid ;  an  uncompli- 
cated typhoid  may  simulate  appendicitis;  a  typhoid  with 
ulceration  of  the  appendix  may  exist;  tuberculosis  and  ap- 
pendicitis may  co-exist,  and,  indeed,  tuberculosis,  typhoid, 
and  appendicitis  may  be  found  in  the  same  individual. 
Although  in  the  present  case  we  were  unable  to  demonstrate 
a  positive  tuberculosis,  I  felt  at  the  time,  and  still  feel,  that 
there  was  probably  a  latent  tuberculous  infection  in  this  boy. 
A  microscopic  report  on  the  lymph-node  states  in  conclu- 
sion, "  The  appearances  are  consistent  with  either  typhoid 
or  acute  inflammation;  probably  typhoid." 

A  confirmatory  positive  Widal  report  was  made  two  days 
later.  The  boy  made  an  excellent  recovery  from  the  opera- 
tion, and  ran  a  very  mild  course  of  typhoid.  Between  three 
and  four  weeks  after  the  operation  he  was  discharged  as  well. 
On  his  return  home  I  directed  his  mother  to  institute  an 
out-of-doors  life  for  him,  and  to  keep  him  from  school  for 
at  least  six  months.  In  the  course  of  the  past  three  years 
he  has  improved  greatly  in  general  condition ;  he  is  practically 
free  from  dyspeptic  symptoms,  and  is  now  a  vigorous,  ath- 
letic school-boy. 


*   INDIGESTION.  255 

Case  79.  On  the  226.  of  February,  1910,  I  was  asked  to 
see  in  consultation  a  man  thirty  years  old,  of  whom  his 
physician  feared  that  he  was  suffering  from  an  abdominal 
abscess.  This  patient,  Mr.  Wills,  had  had  a  long  and  some- 
what complicated  pathological  history.  As  a  boy  of  sixteen 
he  suffered  from  an  osteomyelitis  near  the  head  of  the  right 
femur.  There  was  said  to  have  been  extensive  destruction 
of  bone,  and  invas'ion  of  the  hip  joint.  He  had  been  operated 
upon  a  number  of  times  for  the  removal  of  sequestra  and  the 
drainage  of  abscesses.  I  myself  had  seen  him  from  time  to 
time  during  the  previous  five  years,  and  had  opened  a  number 
of  abscesses.  The  man's  health  in  general  was  good,  and 
his  reaction  vigorous,  so  that  after  opening  abscesses  his 
wounds  would  heal  promptly,  and  he  was  able  to  go  about 
and  lead  a  normal  life.  In  the  course  of  his  bone  disease, 
however,  the  right  hip  had  become  firmly  ankylosed,  and 
he  always  walked  with  a  limp.  However,  he  was  well  de- 
veloped and  nourished,  and  led  an  active,  athletic  life,  so 
far  as  his  infirmity  would  allow.  My  investigation  of  his 
case  from  time  to  time  in  the  past  had  led  me  to  believe  that 
the  acetabulum  was  involved  in  his  bone  disease,  and  that 
possibly  the  pelvis  was  more  or  less  damaged. 

When  I  was  called  to  see  Mr.  Wills  in  February,  1910, 
his  medical  attendant  informed  me  that  he  had  had  proba- 
bly an  appendicitis  for  six  days,  that  the  attack  was  fairly 
characteristic,  with  a  sharp  onset,  accompanied  by  pain, 
nausea,  cramps,  obstinate  constipation,  slight  abdominal 
distention  and  right-sided  rigidity.  The  statement  was 
also  made  that  there  might  possibly  be  an  abscess  present. 

On  examining  the  patient,  who  was  sitting  up  when  I 
arrived,  and  confidently  expecting  a  prompt  subsidence 
of  his  trouble,  I  found  him  to  be  the  robust,  alert  person 
that  I  had  known  previously.  He  had  a  temperature  of 
101°  and  a  pulse  of  100;  the  leukocyte  count  was  22,000. 
He- sat  in  an  easy-chair,  with  his  right  leg  drawn  up,  and 
complained  that  he  had  no  appetite.  When  he  lay  down 
I  found  that  his  abdomen  was  everywhere  slightly  distended, 
that  there  was  a  marked  rigidity  and  spasm  of  the  right 
rectus  and  a  dull  mass  about  the  size  of  two  fists  in  the  right 


256  SURGICAL    PROBLEMS. 

inguinal  region.     A  corresponding  high  fluctuant  area  could 
be  detected  by  the  finger  in  the  rectum.^ 

Mr.  Wills  was  removed  to  a  hospital,  where  I  operated  upon 
him  the  next  day.  I  opened  the  abdomen  through  a  long, 
low  McBurney  incision  immediately  over  the  suspicious 
mass.  I  found  this  mass  well  walled  off  from  the  general 
abdominal  cavity.  Behind  it  lay  the  cecum.  On  opening 
the  mass,  some  six  ounces  of  foul  pus  were  discharged,  and 
at  the  bottom  of  the  abscess  cavity  lay  the  necrotic  stump 
of  the  appendix.  This  was  tied  off  carefully  close  to  the 
cecum.  The  remnants  of  the  appendix  were  removed, 
together  with  two  hard,  fecal  concretions  about  the  size 
of  peanuts.  The  wound  was  carefully  wicked  and  tubed, 
establishing  satisfactory  drainage,  and  the  abdominal  wall 
was  closed  tightly  about  the  drainage  material. ^ 

The  patient  rallied  well  and  was  comfortable  in  the  even- 
ing. He  passed  through  a  week  of  the  usual  fluctuating 
temperature  and  uncertainty  of  outlook,  but  by  the  end 
of  that  time  he  was  progressing  well.  In  spite  of  this  favora- 
ble start,  however,  the  wound  did  not  heal  as  was  expected. 
A  month  after  the  operation  he  left  the  hospital,  with  a 
trifling  sinus,  which  closed  a  few  days  later.  Then  at  the 
end  of  two  weeks  he  suffered  a  return  of  pain  in  the  region 
of  the  scar,  which  looked  red  and  bulging.  I  nicked  it  and 
allowed  about  an  ounce  of  pus  to  escape.  I  inserted  a  wick, 
which  was  renewed  frequently  for  many  weeks.  Four 
months  after  the  operation  the  trifling  sinus  persisted,  dis- 
charging two  or  three  drops  of  pus  daily.  The  organism 
found  was  the  colon  commune  in  pure  culture.  About  this 
time  —  that  is  to  say,  four  months  after  the  operation  — 
one  of  his  old  scars  below  the  hip  joint  swelled  and  required 
opening.  Pus  giving  a  culture  of  staphylococcus  aureus 
was  recovered  from  this  wound.  About  this  time  I  instituted 
a  renewal  of  vaccine  injections,  giving  him  the  colon,  on 
account  of  the  appendix  sinus.  There  was  little  benefit 
from  this;  the  sinus  persisted  for  some  weeks  longer.  About 
the  first  of  September,  however,  the  wound  in  the  leg  had 
healed,  and  shortly  thereafter  the  abdominal  sinus  healed. 
It  seemed  to  me,  and  to  the  consultant  who  prepared  the 


INDIGESTION.  257 

vaccines,  as  though  there  must  be  some  sort  of  communi- 
cation between  the  inflammation  in  the  thigh  and  the 
inflammation  in  the  abdomen,  but  we  were  never  able  to  dis- 
cover any  immediate  channel  of  communication,  nor  were 
the  cultures  from  the  two  wounds  identical.  It  is  an  in- 
teresting observation,  however,  that  the  closure  of  the  one 
wound  was  soon  followed  by  the  closure  of  the  other.  Since 
September,  1910,  the  patient  has  remained  well.^ 

^  At  first  sight,  this  patient  seemed  to  be  suffering  un- 
questionably from  an  acute,  but  neglected,  appendicitis. 
One  remembers,  however,  that  certain  other  ailments  simu- 
late or  complicate  appendicitis,  especially  tuberculosis,  can- 
cer and  some  infection  of  the  retro-peritoneal  glands.  In  the 
case  of  our  patient  there  was  also  the  old  story  of  bone 
disease,  with  a  possibility  that  the  present  condition  might 
be  due  to  spreading  infection  from  the  acetabulum. 

^  During  the  past  few  years  surgeons  have  largely  aban- 
doned the  old-fashioned  method  of  extensive  wicking  in 
these  cases,  and  leaving  the  wound  wide  open.  Apparently 
there  is  nothing  gained  by  that  ancient  method.  It  suffices 
to  close  the  wound  so  far  as  possible  about  the  drains.  If 
there  be  a  further  spread  of  infection,  and  the  formation 
of  secondary  pus  pockets,  the  wound  can  readily  be  opened. 
Conversely,  should  the  wound  heal  promptly,  as  is  usually 
the  case,  the  careful  sewing  up  of  the  split  muscles  antici- 
pates and  prevents  hernia  in  many  cases.  I  employ  appro- 
priate vaccines  invariably  in  the  case  of  these  drained 
appendix  wounds. 

^  Every  surgeon  is  familiar  with  the  irritating  presence  of 
a  long-suppurating  abdominal  sinus  after  an  operation. 
These  sinuses  are  commonly  due  to  some  deep-seated  infec- 
tion which  refuses  to  subside,  or  perhaps  most  often  to  the 
irritating  presence  of  an  infected  ligature.  Possibly  some 
such  explanation  is  the  true  one  in  the  case  of  Mr.  Wills, 
but,  if  so,  the  opening  and  closing  of  the  abscess  in  the 
thigh  must  be  regarded  as  a  curious  coincidence. 


•  BORDERLAND. 

Case  80.  On  the  15th  of  March,  1910,  Mr.  John  A.  Mutt, 
a  lawyer  of  thirty-five  and  unmarried,  with  a  long,  indefi- 
nite and  familiar  story,  came  to  see  me.  Up  to  three  months 
before,  his  health  had  been  excellent.  He  was  an  athletic, 
vigorous,  out-of-doors  man,  who  never  thought  of  illness. 
On  the  1st  of  December,  1909,  however,  he  experienced  a 
dull  pain  in  his  right  side,  below  the  costal  margin.  In  the 
course  of  a  day  or  two  the  pain  became  so  wearing  that  he 
consulted  his  physician,  who  sent  him  to  bed.  The  pain 
was  not  excruciating,  but  was  constant,  and  was  accom- 
panied by  fever  and  prostration.  When  he  lay  still  he  was  com- 
fortable, but  the  pain  was  aggravated  by  the  slightest  move- 
ment. He  told  me  that  there  were  no  other  symptoms 
and  that  his  physician  was  puzzled.  An  internist  saw  him 
in  consultation,  and  examined  carefully  into  the  condition 
of  his  kidneys,  his  gall  bladder,  his  intestines,  his  stomach 
and  other  adjacent  organs,  but  was  able  to  arrive  at  no  con- 
clusion regarding  them.  The  illness  ran  on  for  some  two 
months,  or  until  about  the  ist  of  February;  then  the  pain 
lessened,  and  finally  ceased,  and  the  patient  was  allowed 
to  go  about.  He  had  been  at  his  business  for  two  weeks 
when  he  consulted  me.  Three  days  before  I  saw  him  the 
pain  recurred  in  a  mild  degree,  making  him  anxious  and 
irritable.  He  told  me  that  during  the  winter  he  lost  twenty 
pounds  in  weight  and  became  fretful,  and  unequal  to  his 
daily  work.  In  order  to  pick  up  any  possible  lost  threads 
of  his  story,  I  talked  over  the  telephone  with  his  two  physi- 
cians, and  learned  that  they  regarded  the  case  as  possibly 
one  of  subphrenic  abscess,  but  were  unable  to  make  a  positive 
diagnosis.^ 

On  his  consulting  me  I  saw  that  Mr.  Mutt  presented  a 
serious  and  difficult  problem,  and  I  therefore  exerted  myself 
in  every  way  to  arrive  at  some  conclusion  regarding  him. 
My  first  physical  examination  revealed  a  tall,  well-developed 

259 


260  SURGICAL    PROBLEMS. 

young  man,  somewhat  emaciated  and  hectic  in  appearance, 
with  sound  organs  above  the  diaphragm  and  with  a  tem- 
perature of  103°.  He  was  highly  inteUigent,  and  answered 
accurately  questions  put  to  him.  At  the  same  time  he 
professed  himself  willing  to  submit  to  any  necessary  investi- 
gation. His  abdomen  was  somewhat  retracted.  He  pointed 
to  the  right  costal  margin  and  to  the  right  lumbar  region 
as  the  seats  of  his  pain  and  discomfort.  On  examining  him 
by  deep  palpation  I  found  a  slight  tenderness  in  the  right 
costo-vertebral  angle  and  over  the  cecum,  but  absolutely 
nothing  else.  Careful  urinalysis  at  that  time  revealed  an 
apparently  normal  urine.  The  patient  stated  further  that 
he  had  a  good  appetite  and  could  not  understand  his  loss 
of  flesh. 

I  sent  him  to  a  hospital  for  rest  in  bed  and  further  inves- 
tigation. While  he  was  there  I  had  a  careful  analysis  made 
of  the  stools  and  gastric  content,  but  nothing  peculiar  was 
found.  Repeated  tuberculin  tests  failed  to  elicit  any  reac- 
tion. I  then  had  made  a  careful  cystoscopic  examination 
of  his  bladder,  with  an  analysis  of  the  segregated  urines. 
The  cystoscope  showed  a  bladder  normal  in  every  particu- 
lar, with  normal  ureteral  openings.  The  segregated  urines 
came  in  equal  abundance,  and  with  the  characteristic  stain 
after  indigo-carmine,  in  ten  minutes  from  both  kidneys. 
There  was  nothing  peculiar  in  the  urethra.  As  my  consult- 
ant stated  at  the  time,  however,  this  might  well  be  coinci- 
dent with  a  quiescent  stone  or  a  relapsing  pyelitis  as  possi- 
ble conditions  in  the  right  kidney,  but  his  final  statement 
was,  "  I  cannot  make  a  definite  diagnosis  of  kidney  disease." 
After  a  week  in  bed,  Mr.  Mutt  was  free  from  his  old  pains 
in  the  back  and  upper  abdomen,  but  at  the  end  af  that  time, 
on  deep  and  careful  palpation  along  the  spinal  column  low 
in  the  abdomen,  I  was  able  to  elicit  invariably  a  point  of 
pain  about  two  inches  to  the  right  of  the  navel,  not  far  from 
McBurney's  point. ^  This  strongly  suggested  appendicitis, 
and  after  repeated  examinations,  with  the  same  result, 
I  was  able  so  to  inform  the  patient.  I  then  advised  an  ex- 
ploratory operation,  a  proposition  which  he  accepted  cheer- 
fully as  a  future  alternative,  but  up  to  the  present  time,  as 


BORDERLAND.  26l 

he  has  remained  well,  he  has  thought  best  to  postpone  further 
treatment.^ 

^  Pain  immediately  below  the  right  costal  margin  suggests, 
of  course,  a  number  of  different  conditions,  especially  disease 
of  the  bile  passages,  intercostal  neuralgia,  disease  of  the 
kidney,  colon,  liver,  subphrenic  region,  and  possibly  of  the 
appendix,  while  the  more  remote  stomach  and  pancreas 
must  not  be  left  out  of  consideration.  In  Mr.  Mutt's  case, 
the  fever,  prostration  and  emaciation  suggest  strongly  the 
presence  of  some  infected  joint  and  some  inflammatory 
process,  but  the  absolute  lack  of  other  confirmatory  symp- 
toms leaves  the  consultant  very  much  in  the  dark. 

^  This  point  in  the  region  of  the  right  inguinal  lymph- 
nodes  is  the  point  insisted  upon  by  Robert  Morris  as  indi- 
cating a  probable  infection  of  the  appendix.  The  suggestion 
is  well  taken,  and  I  have  found  Morris's  point  of  great  serv- 
ice in  diagnosis  in  a  number  of  cases.  Persistent  tenderness 
at  this  point  may  also  indicate  an  impacted  ureteral  calculus, 
a  lesion  not  infrequently  confused  with  appendicitis.  I 
believe,  however,  that  the  ureteral  examination,  which  was 
made  by  a  careful  expert,  should  justify  us  in  ruling  out  a 
calculus  in  the  present  case. 

^  The  story  of  this  patient,  while  unsatisfactory  from  the 
point  of  view  of  diagnosis,  is  extremely  instructive  from  the 
point  of  view  of  the  general  treatment  of  obscure  cases. 
I  have  long  held  that  our  present  method  of  dealing  with 
persons  of  small  means  who  are  the  subjects  of  obscure  illness 
is  unsatisfactory.  Patients  of  the  poorest  class  can  secure 
expert  examination  and  advice  by  entering  a  large  hospital, 
where  they  have  the  benefit  of  numerous  consultations 
with  different  experts.  Much  in  the  same  way,  wealthy 
persons  can  employ  the  services  of  numerous  experts  to 
determine  their  ailments,  while  they  pay  large  fees  for  such 
information.  Persons  of  limited  means,  however,  must 
not  expect  to  be  treated  as  paupers,  nor  can  they  afford 
numerous  expert  opinions.  Such  was  the  case  with  Mr.  Mutt. 
He  lay  in  bed  many  months  without  a  satisfactory  investi- 
gation of  his  case.  His  family  physician,  although  a  man 
of  excellent  attainments,  was  unable  to  provide  several 
expert  opinions,  and  the  patient  suffered  from  that  fact. 
His  consultation  with  me  and  the  subsequent  investigations 
by  my  special  consultants  were  matters  of  serious  moment 
to  the  patient,  on  account  of  the  anticipated  expense.  I 
believe  the  time  will  come  when  it  will  be  possible  for  groups 
of  physicians,   acting   in   concert,    to   investigate   and   treat 


262  SURGICAL   PROBLEMS. 

diseases  of  persons  in  small  circumstances,  and  at  moderate 
fees.  As  the  situation  stands  at  present,  most  of  those 
unfortunate  patients  are  cut  off  from  the  best  of  modern 
scientific  medicine. 


BORDERLAND.  '  263 

Case  81.  While  the  surgeon  can  often  clear  up  a  diag- 
nosis by  operation,  it  is  a  mistake  to  suppose,  as  non-medical 
persons  frequently  do  suppose,  that  operation  is  the  end-all 
of  surgery.  The  following  case  illustrates  this  fact,  while 
it  illustrates  the  value  of  patient  inaction  also, 

Mrs.  J.  G.  Jackson  had  been  seriously  ill  for  two  days  when 
I  was  asked  by  her  physician  to  see  her,  on  the  I2th  of  August, 
1910.  She  was  sixty  years  of  age,  and  the  mother  of  three 
children.  She  had  had  an  umbilical  hernia  for  thirty  years, 
as  well  as  troublesome  hemorrhoids,  but  no  treatment  for 
either  condition.  Five  years  previously,  in  1905,  she  suffered 
from  a  sudden,  agonizing  attack  of  epigastric  pain,  which 
was  promptly  relieved  by  vomiting,  and  never  recurred 
until  this  time.  In  all  other  respects  she  had  been  a  well 
and  vigorous  woman,  so  far  as  was  known  to  her  physician. 
I  have  stated  that  the  illness  for  which  I  was  called  had 
lasted  two  days.  It  was  characterized  by  a  severe  recurrence 
of  the  epigastric  pain,  which  persisted, —  pain  shooting  into 
the  right  hypochondrium  below  the  gall  bladder,  prostrat- 
ing and  agonizing.  She  was  a  woman  of  moderate  means 
and  was  unwilling  to  employ  a  nurse,  and  owing  to  her  irri- 
tability and  restlessness  had  not  been  confined  to  her  bed, 
but  had  been  up  and  down  about  her  sick-room  since  the 
onset  of  the  attack.  There  had  been  no  vomiting  or  nausea; 
her  bowels  had  not  moved  for  four  days.  The  history  went 
no  further. 

I  found  Mrs.  Jackson  to  be  an  enormously  fat  woman, 
five  feet  six  inches  in  height,  and  weighing  three  hundred 
pounds.  As  she  lay  In  bed  I  could  see  little  but  a  moun- 
tainous abdomen  elevating  the  bed-clothes.  Her  heart  was 
rather  feeble,  beating  at  the  rate  of  106,  with  a  soft  pulse. 
The  heart  appeared  to  be  somewhat  enlarged  also,  so  far  as 
we  could  make  out  through  the  massive  chest  wall,  but  no 
valvular  murmurs  could  be  heard.  The  patient  looked  very 
sick,  —  purple,  red-eyed,  anxious,  short  of  breath,  peevish. 
Her  temperature  was  102°,  her  chest  was  clear,  her  urine 
was  not  peculiar;  the  leukocyte  count  was  14,000.  Her 
abdomen  was  enormous,  as  I  have  stated,  and  carried  a 
considerable  umbilical  hernia,   the  size  of  two  fists,  which 


264  SURGICAL    PROBLEMS. 

was  not  tender  and  appeared  to  contain  omentum  only. 
There  was  marked  abdominal  distention  also,  very  great  above 
the  navel,  less  conspicuous  below  It.  There  was  extreme 
tenderness  throughout  the  epigastrium  and  considerable 
tenderness  in  the  right  hypochondrium.  In  the  right  hypo- 
chondrium  there  was  an  area  also,  the  size  of  a  child's  hand, 
halfway  between  the  ribs  and  the  navel,  brawny  and  pe- 
culiarly tender,  suggesting  somewhat  an  infection  of  the 
abdominal  wall/  As  I  have  stated,  her  bowels  had  not  moved 
for  four  days,  except  once  very  slightly  and  painfully  after 
a  large  dose  of  calomel,  a  drug  not  to  be  recommended  in 
cases  of  apparent  inflammatory  obstruction. 

Mrs.  Jackson's  case  was  another  of  those  obscure  ones  which 
no  man  may  determine  accurately  at  the  first  examination, 
her  great  size  and  fat  abdominal  wall  rendering  a  positive 
decision  especially  difficult.  Disease  of  the  gall  bladder  and 
ducts  was  the  first  and  most  obvious  suggestion,  but  we  had 
to  regard  as  possible  some  complication  of  appendicitis 
and  as  not  improbable  a  malignant  disease  of  the  colon, 
penetrating  and  involving  neighboring  structures.  I  could 
say  little  more  at  the  time  than  that  there  appeared  to  be 
an  acute,  inflammatory  intestinal  obstruction  present. 

The  prognosis  was  extremely  grave  and  the  question  of 
treatment  difficult.  We  are  all  familiar  with  the  hazard 
of  operating  upon  elderly,  fat  persons  with  weak  hearts, 
yet  it  seemed  as  though  I  should  be  forced  to  suggest  an 
operation  for  Mrs.  Jackson.  I  put  the  case  fairly  before  the 
patient  and  her  husband,  and  confessed  that  I  saw  little 
prospect  of  cure  by  an  operation.  We  determined,  therefore, 
to  adopt  an  attitude  of  "  masterly  inactivity."  Mrs.  Jack- 
son was  removed  to  a  hospital,  was  given  a  special  nurse 
and  a  course  of  absolute  starvation.  At  the  same  time 
she  was  supplied  with  water  by  proctoclysis,  the  head  of 
her  bed  was  elevated,  her  shoulders  were  properly  supported 
and  she  was  made  as  comfortable  as  possible.  I  started  her 
off  with  a  good  dose  of  morphia,  which  I  believe  is  always 
effective  in  these  cases,  in  spite  of  many  theoretical 
objections  to  its  use.^ 


BORDERLAND.  265 

^  The  attack  of  epigastric  pain  five  years  before  and  the 
nature  of  the  present  attack  suggest  possible  disease  of  the 
bile  passages,  with  serious  infection  of  the  gall  bladder. 
Some  years  ago,  in  a  very  similar  case,  I  operated  on  a  patient 
cutting  down  into  the  brawny  region  which  existed  there  also. 
I  supposed  that  I  should  open  an  infected  abdominal  wall. 
I  did  so,  indeed,  but  discovered  behind  the  sheath  of  the 
rectus  a  considerable  gallstone,  which  had  ulcerated  through 
from  the  gall  bladder  and  was  endeavoring  to  force  its  way 
outward.  Doubtless  had  I  left  it  alone,  an  abscess  would 
have  resulted,  and  probably  the  gallstone  eventually  would 
have  been  discharged  through  the  skin. 

^  I  remember  clearly  a  similar  case  in  a  man  under  my 
care  some  fifteen  years  ago,  in  whom  I  made  the  diagnosis 
of  stercoral  ulcer  at  the  splenic  flexure  of  the  colon.  That 
patient  appeared  to  be  dying  of  diffuse  peritonitis.  It  was 
long  before  our  modern  conception  of  intestinal  rest.  I 
withheld  from  him  all  food,  and  even  water,  and  tied  up  his 
intestines  with  morphia.  Greatly  to  my  interest  and  much 
to  my  surprise,  he  suddenly  began  to  mend,  and  has  been 
a  well  man  for  many  years. 

The  patient  passed  a  fairly  comfortable  night.  The  next 
morning  her  temperature  had  fallen  to  99°  and  her  pulse 
to  88.  Keeping  her  still  on  a  starvation  diet,  without  even 
water  by  the  mouth,  I  instituted  a  course  of  rectal  feeding, 
—  salt  solution  with  albumen.  After  twenty-four  hours  more 
she  was  perfectly  comfortable;  her  fever  had  disappeared; 
her  pulse  was  steady,  of  good  volume  and  slow;  her  dis- 
comfort was  gone,  and  her  usual  serene  and  optimistic 
attitude  had  returned.  She  continued  to  improve.  After 
four  days  she  felt  perfectly  well;  at  the  end  of  ten  days 
she  was  walking  about,  and  at  the  end  of  two  weeks  she  went 
home,  wearing  a  carefully  fitted  abdominal  belt,  which 
supported  her  great  abdomen  and  held  securely  the  umbili- 
cal hernia.  I  have  heard  from  her  recently,  and  learn  that 
she    has    enjoyed    good    health    since    leaving    the    hospital. 

While  the  diagnosis  in  this  case  is  not  yet  cleared  up,  we 
are  justified  In  feeling  that  proper  measures  were  taken  and 
that  In  all  probability  the  more  radical  measure  of  operating 
would  have  killed  the  patient. 


ABDOMINAL. 

Case  82.  For  twenty-five  years  Mrs.  George  P.  White 
had  been  an  active,  robust  woman,  with  little  thought  of 
invaUdism.  She  was  forty-eight  years  old  when  I  was  called 
to  see  her,  on  the  15th  of  March,  1906.  Married  at  twenty- 
three,  she  had  two  children,  aged  respectively  twenty  and 
eighteen.  There  was  some  question  of  her  having  had  a  pel- 
vic infection  shortly  before  the  birth  of  her  eldest  child, 
though  the  question  was  unsettled  and  obscure.  At  any  rate, 
she  recovered  and  had  borne  her  children  without  spe- 
cial disturbance.  In  1896  she  was  confined  to  her  bed  for 
a  period  of  two  weeks  with  rather  excessive  flowing,  but 
this  passed  off  without  recurrence.  She  was  subject  to  at- 
tacks of  dyspepsia,  occasional  distress  after  meals,  sometimes 
coming  on  two  hours  after  taking  food,  lasting  one  or  two 
hours,  and  again  relieved  by  food.  These  attacks  were  al- 
ways allayed  by  abundant  dosing  with  bicarbonate  of  soda. 
As  she  approached  middle  age  she  grew  fat,  and  the  dys- 
peptic attacks  decreased  in  frequency.  In  1900  she  was  laid 
up  with  a  long  course  of  typhoid  fever,  which  left  her  de- 
bilitated for  a  year,  but  from  that  also  she  recovered. 
Her  catamenia  had  always  been  regular  and  not  excessive 
since  the  time  of  flowing  ten  years  before.  Both  her  children 
were  well  and  vigorous,  —  one  a  divinity  student,  the  other 
a  girl  active  in  good  works,  in  which  Mrs.  White  herself 
was  keenly  interested.  Two  weeks  before  I  saw  Mrs.  White 
she  had  a  sudden  attack  of  abdominal  pain  in  the  middle 
of  the  night ;  not  such  epigastric  pain  and  distress  as  she  had 
been  used  to  associate  with  dyspepsia,  but  pain  lower  down, 
in  the  neighborhood  of  the  navel,  steady,  grinding,  sickening, 
with  extreme  tenderness  between  the  pubes  and  the  navel. 
At  that  time  also  there  was  considerable  abdominal  dis- 
tention, and  for  two  days  obstinate  constipation,  the  tempera- 
ture ranging  from  101°  to  103°  and  the  pulse  in  the  neigh- 
borhood of  no.    With  rest  in  bed  and  external  applications, 

267 


268  SURGICAL    PROBLEMS. 

the  pain,  soreness  and  constipation  subsided.  She  had  been 
through  a  menstrual  period  just  before  this  attack,  but  had 
observed  nothing  unusual  about  the  period.  After  the  sub- 
sidence of  the  abdominal  pain  the  patient  remained  sore 
and  weak,  with  constipation  and  no  appetite.  She  asked  for 
nothing  better  than  to  be  let  alone.  Four  days  later,  and 
again  five  days  later,  she  suffered  from  similar  attacks,  last- 
ing two  or  three  days,  with  complete  subsidence  of  symptoms 
between  the  attacks,  but  without  a  proper  sense  of  con- 
valescence. When  I  saw  her  she  was  rallying  from  her 
third  attack.  The  condition  seemed  to  be  one  of  some 
obscure,  subacute  infection,  the  cause  far  from  obvious. 

I  found  Mrs.  White  to  be  a  large,  stout,  placid,  intelli- 
gent woman,  with  a  temperature  of  ioo°  and  pulse  84. 
The  chest  examination  was  negative.  Her  heart  was  sound 
and  competent.  There  was  a  general  abdominal  disten- 
tion, most  marked  above  the  navel,  as  though  the  stomach 
and  colon  were  blown  up.  There  was  exquisite  tenderness 
above  the  pubes  and  on  both  sides,  suggesting  damage  to 
the  uterus  and  its  adnexa.  The  appendix  region  was  not 
peculiar,  nor  was  there  special  tenderness  to  be  brought 
out  by  deep  palpation  on  either  side  of  the  umbilicus.  Bi- 
manual examination  of  the  pelvis  was  unsatisfactory,  owing 
to  the  extreme  tenderness  of  the  patient.  I  made  out  the 
uterus  to  be  about  the  size  of  two  fists,  and  tender  to  hand- 
ling. There  was  extreme  tenderness  also  in  either  fossa. 
Except  for  the  large  uterus,  I  could  ascertain  nothing  definite, 
as  the  patient  would  bear  no  further  manipulation,  and 
it  did  not  seem  wise  at  that  time  to  give  an  anesthetic.^ 
I  was  unable  to  make  a  definite  diagnosis  further  than  the 
obvious  one  that  the  pelvic  organs  were  inflamed  and  that 
in  my  judgment  no  present  operation  should  be  done.  I 
believed,  however,  that,  if  the  subacute  process  quieted  down, 
the  uterus  should  be  curetted,  and  possibly  a  subsequent 
hysterectomy  should  be  performed. 

Four  days  later  I  was  summoned  in  great  haste  by  Mrs. 
White's  physician,  to  operate  in  an  emergency.  He  stated 
that  the  day  after  I  first  saw  her  she  began  to  flow  and  had 
flowed   severely  ever  since.     She  was  becoming  exhausted. 


ABDOMINAL.  269 

When  I  reached  the  house,  which  was  In  a  town  some  twenty 
miles  from  Boston,  I  found  Mrs.  White  much  worse.  Her 
pulse  had  run  up  to  120,  she  was  blanched  and  feeble,  her 
temperature  was  said  to  fluctuate  between  98°  and  102°. 
The  abdominal  distention  persisted,  but  the  evidence  of  an 
exhausting  infection  was  far  more  marked.  I  regarded  her 
as  an  extremely  bad  operative  risk,  and  had  it  not  been  for 
the  flowing  I  would  have  refused  to  submit  her  to  any  opera- 
tion. The  flowing,  however,  was  so  obstinate  and  depleting 
that  there  seemed  no  way  out  of  the  dilemma  save  to  give 
an  anesthetic  and  endeavor  to  check  the  hemorrhage.  Ac- 
cordingly, the  patient  was  etherized  and  her  uterus  curetted. 
Large  masses  of  detritus  were  removed  and  the  uterus  packed, 
but  the  hemorrhage  persisted.  As  the  patient  was  bearing 
the  operation  well,  I  went  on  hastily  to  a  further  investiga- 
tion. I  opened  the  abdomen  and  explored  the  pelvis.  The 
intestines  were  adherent  everywhere  to  the  pelvic  viscera, 
glued  by  numerous  fresh  adhesions.  The  left  tube  and  ovary 
were  distended  and  necrotic,  the  right  tube  was  adherent 
to  the  uterus  and  the  right  ovary  was  necrotic.  In  other 
words,  the  blood  supply  of  the  adnexa  was  greatly  dimin- 
ished. There  were  further  adhesions  deep  in  the  pelvis, 
showing  evidence  of  an  old  inflammatory  process  there. 
In  the  midst  of  these  adhesions  was  a  pocket  containing  six 
ounces  of  pus,  behind  the  uterus.  The  uterus  itself  was  en- 
larged to  the  size  of  two  fists,  boggy,  friable  and  easily 
bleeding.  Indeed,  all  the  pelvic  organs  were  most  friable. 
I  removed  rapidly  the  tubes  and  ovaries,  and  as  the  patient 
still  remained  in  fair  condition  I  carried  the  dissection  still 
further  and  amputated  the  uterus  itself  above  the  cervix. 
The  whole  operation  was  an  offense  to  one's  surgical  judg- 
ment and  aseptic  sense.  It  was  impossible  to  prevent  soil- 
ing the  peritoneum,  as  the  contents  of  the  pelvis  were  ex- 
tremely foul.  So  far  as  the  patient's  condition  would  permit, 
I  cleaned  up  the  pelvis  carefully  and  closed  the  uterine  stump, 
attaching  it  firmly  to  the  broad  and  round  ligaments.^ 
The  abdomen  was  closed,  with  stab-wound  drainage,  and 
a  separate  drain  from  behind  the  cervix  was  carried  down 
through  the  vagina.     The  operation  was  long  and  the  dis- 


270  SURGICAL    PROBLEMS. 

section  tedious,  but  the  patient  bore  it  with  surprising 
strength.     She  rallied  well. 

The  care  of  the  patient  for  the  next  week  was  exacting 
and  difficult,  and  was  carried  out  by  my  consultant  most 
intelligently  and  conscientiously.  We  employed  with  great 
effect  continual  proctoclysis,  and  the  patient  was  able  to 
bear  the  semi-upright  position  without  complaint.  The 
salt  solution  seeped  into  the  rectum,  was  taken  up  rapidly, 
and  its  good  effects  were  shown  by  the  increased  activity 
of  the  kidneys,  diminution  of  thirst  and  the  goodly  amount 
of  fluid  poured  out  through  the  drainage  wicks. 

The  next  day  the  patient  suffered  little  pain ;  she  looked 
better.  Her  pulse  was  100,  her  temperature  98.8°  in  the 
morning.  From  that  time  on  she  made  steady  progress, 
greatly  to  my  satisfaction  and  not  a  little  to  my  surprise. 
We  took  out  the  wicks  on  the  third  day;  on  the  seventh 
day  the  wounds  were  healed,  and  in  three  weeks  she  was 
able  to  sit  up,  and  pronounced  herself  better  than  for  many 
previous  months.  She  has  continued  ever  since  in  active 
and  steady  health.^ 

^  The  question  of  diagnosis  up  to  this  point  was  extremely 
obscure.  The  enlargement  of  the  uterus  and  the  apparent 
involvement  of  the  tubes  and  ovaries  suggested  an  infection, 
yet  there  was  no  apparent  source  for  the  infection,  there 
was  no  uterine  discharge,  there  was  no  evidence  of  gonorrhea, 
there  had  been  no  miscarriage  or  recent  childbirth.  A  tu- 
mor of  the  uterus,  if  necrotic  and  infected,  might  give  signs 
like  those  I  have  described,  but  the  common  tumor  of  the 
uterus,  myoma,  rarely  becomes  infected  except  after  parturi- 
tion, when,  the  blood  supply  being  cut  off  or  diminished, 
the  tumor  is  peculiarly  liable  to  necrotic  or  infective  changes. 

^  In  cases  of  supravaginal  hysterectomy  the  suspension 
of  the  cervical  stump  by  the  broad  and  round  ligaments 
is  an  important  step,  for  such  suspension  holds  up  the  pel- 
vic floor  and  takes  much  of  the  weight  of  the  superimposed 
viscera,  which,  otherwise  tend  to  produce  pelvic  hernia. 

^  I  have  indicated  my  satisfaction  and  surprise  in  the 
outcome  of  this  case.  These  serious  pelvic  infections  by  no 
means  always  promise  so  satisfactory  a  result.  Secondary 
hemorrhage  after  such  an  operation  as  I  have  described  is 
common.  Spreading  infections  are  common  also.  If  Mrs. 
White  had  been  a  poorly  nourished,  worn-out  woman,  she 


ABDOMINAL.  2"]! 

would  undoubtedly  have  died.  Her  speedy  and  satisfactory 
recovery  must  be  laid  in  large  measure  to  her  previous 
vigorous  health.  Even  so,  the  operation  was  imperative  and 
would  have  been  undertaken  in  any  case  except  in  the  face 
of  extreme  collapse  and  impending  death. 


272  SURGICAL   PROBLEMS. 

Case  83.  Miss  Minnie  Locke  at  the  age  of  forty-six  was 
living  in  a  remote  New  Hampshire  hill  town.  She  had  been 
a  school-teacher,  but  the  course  of  her  health  had  been 
troubled,  and  for  fifteen  years  she  had  nursed  a  chronic 
dyspepsia,  when  I  saw  her  on  September  i,  1908. 

As  I  look  back  now  at  the  case,  I  have  no  doubt  that  she 
was  the  victim  of  a  pronounced  enteroptosis,  but  in  1908 
I  was  less  alert  to  the  frequency  of  that  condition  than 
we  are  at  present. 

Miss  Locke  was  a  woman  of  moderate  education  and  fair 
intelligence,  given  to  introspection  and  to  long  sustained 
arguments  regarding  her  numerous  symptoms.  She  was 
brought  to  me  as  an  emergency  case  by  her  physician,  who 
rushed  her  from  the  station  in  Boston  to  the  hospital.  On 
questioning  the  patient,  I  learned  that  she  was  perfectly 
well  and  active  up  to  the  age  of  twenty,  when  she  suffered 
a  grievous  disappointment,  probably  a  blow  to  her  affec- 
tions. From  that  time,  although  for  some  years  busy  as  a 
school-teacher,  she  had  never  known  sound  health.  She 
was  dyspeptic;  that  is  to  say,  she  felt  oppressed  by  what- 
ever food  she  ate,  and  limited  herself  to  a  small  and  simple 
diet.  She  was  troubled  by  constant  flatulence  also.  These 
symptoms,  however,  pointed  to  nothing  positive  and  did  not 
suggest  gastric  or  duodenal  ulcer.  She  was  constipated,  and 
dependent  on  large  doses  of  senna.  She  was  the  victim 
of  frequent  racking  headaches,  which  attacked  her  almost 
weekly  and  left  her  prostrate  for  many  hours.  She  had 
had  some  swelling  of  the  neck,  but  this  had  disappeared  when 
I  saw  her.  Her  eyes  had  troubled  her  for  five  years  or  more, 
accommodating  slowly  and  causing  blurring  of  vision.  She 
had  recurring  palpitations  of  the  heart,  her  pulse  running 
up  often  to  120  and  130  on  the  slightest  exertion,  her  physi- 
cian said.  She  was  emaciated,  weighing  one  hundred  and 
fifteen  pounds,  twenty  pounds  below  her  best  weight.  She 
was  troubled  with  bloating  of  the  abdomen.^ 

On  making  a  careful  physical  examination  of  this  patient 
I  was  unable  at  first  to  arrive  at  any  satisfactory  diagnosis. 
The  symptoms  of  Graves'  disease  which  I  have  suggested 
were  obscure;  there  was  no  exophthalmos;  there  was  no  thy- 


ABDOMINAL.  273 

roid  tumor;  the  pulse  was  loo,  but  the  heart  was  not  affected; 
there  was  little  or  no  muscular  tremor,  and  the  patient  was 
fairly  steady,  with  a  forced  cheerfulness.  My  examination 
of  the  chest  was  otherwise  negative.  An  examination  of 
the  abdomen  revealed  little  at  first.  The  stomach  was  evi- 
dently somewhat  enlarged  and  slightly  prolapsed,  so  far 
as  percussion  demonstrated,  and  the  same  was  true  of  the 
colon.  The  right  kidney  also  was  extremely  movable  and 
slid  down  readily  towards  the  pelvis.  When  I  had  pro- 
ceeded so  far  with  my  examination,  the  patient  suddenly 
remembered  that  for  some  years  her  catamenia  had  been 
irregular  and  that  for  at  least  two  years  she  had  been  troubled 
with  excessive  flowing  about  once  every  six  weeks.  This 
important  fact  was  confided  to  me  with  hesitation.  On 
further  examination,  accordingly,  I  discovered  a  uterus  some- 
what enlarged,  about  the  size  of  two  closed  fists,  movable, 
rather  tender,  retroverted  in  the  second  degree  and  retro- 
cessed,  not  nodular,  the  adnexa  not  peculiar,  except  for 
an  indefinite  sense  of  resistance  to  the  right  of  the  uterus 
suggesting  possibly  the  presence  of  a  small  ovarian  cyst.^ 

1  The  symptoms  which  I  have  named  suggest  strongly  two 
serious  conditions,  Graves'  disease  and  gastro-enteroptosis, 
especially  Graves'  disease,  though  the  toxemia  associated 
with  enteroptosis  often  simulates  closely  the  toxemia  of 
Graves'  disease. 

2  The  complex  of  signs  and  symptoms  up  to  this  point 
was  rather  puzzling.  Obviously  the  woman  was  an  invalid, 
but  whether  the  psychic  state  was  more  pronounced  than 
the  physical  one  was  a  question.  It  did  not  seem  likely  to 
me  that  the  small  uterine  myoma  was  the  cause  of  all  the 
symptoms,  neither  did  the  small  amount  of  ptosis  which 
I  was  then  able  to  make  out  appear  responsible. 

The  next  day  the  patient  told  me  that  after  my  examina- 
tion she  had  had  constant  low  abdominal  pain,  that  her  appe- 
tite had  vanished  and  that  she  felt  very  ill.  In  appearance 
she  had  not  changed;  her  temperature  was  normal  and  her 
pulse  between  90  and  100,  Excessive  uterine  flowing  had 
come  on,  however,  and  I  ascertained  that  her  hemoglobin 
was  60%.     It  seemed  best,  therefore,  to  operate  at  once  and 


274  SURGICAL   PROBLEMS. 

remove  the  uterus.  I  did  so,  amputating  the  uterus  at  the 
cervix  through  an  abdominal  incision.  There  was  a  small 
cystic  ovary  present,  which  was  removed  also.  A  rather 
thickened  and  adherent  appendix  was  taken  out  at  the 
same  time.  The  patient  rallied  well,  the  wound  healed 
promptly,  and  two  weeks  later  she  was  ready  to  leave  the 
hospital.  Nevertheless,  she  was  far  from  well;  the  dyspeptic 
symptoms  persisted  and  she  complained  constantly  of  great 
lassitude  and  headache,  while  the  constipation  was  more 
troublesome  than  ever. 

In  order  to  ascertain  more  accurately  the  state  of  the  ab- 
dominal organs  before  discharging  the  patient,  I  reviewed 
again  my  notes  of  the  operation,  and  read  that  the  cecum 
was  low  in  the  pelvis,  that  the  lower  border  of  the  stomach 
was  far  down  and  that  the  transverse  colon  was  prolapsed. 
These  facts,  which  we  now  recognize  as  due  to  a  congenital 
ptosis,  had  not  especially  impressed  me  at  the  time.  Every 
operating  surgeon  realizes  that  it  is  a  common  thing  to 
find  a  low-lying  stomach  and  colon.  That  fact  has  been 
remarked  upon  a  thousand  times,  but  only  recently  have 
operating  surgeons  recognized  the  importance,  and  often 
the  seriousness,  of  such  low-lying  hollow  organs.  In  Miss 
Locke's  case  I  realized  with  fair  accuracy  that  her  visceral 
ptosis  might  have  an  important  bearing  on  her  miserable 
psychic  and  physical  condition.  I  therefore  had  her  fitted 
with  a  carefully  made  corset-belt,  according  to  the  pattern 
which  I  was  then  using,  and  was  gratified  to  find  that  within 
a  week  she  had  improved  distinctly,  both  mentally  and  physi- 
cally. She  then  left  the  hospital.  I  have  seen  her  a  number 
of  times  during  the  past  three  years.  I  have  had  careful 
x-rays  made  of  the  stomach  and  colon.  While  they  are 
still  prolapsed,  they  give  much  less  trouble  than  formerly, 
because  they  are  held  up  and  the  strain  on  the  mesentery 
is  relieved  by  proper  external  supports. 


ABDOMINAL.  275 

Case  84.  Problems  which  arc  no  problems  frequently 
concern  the  physician  and  the  surgeon.  Mrs.  James  Perkins 
illustrates  a  common  condition.  She  was  a  woman  of  forty- 
five,  who  came  to  see  me  on  the  5th  of  January,  1909.  She 
had  been  for  ten  years  under  the  observation  of  various 
physicians,  in  no  one  of  whom  had  she  trusted  long  enough 
to  allow  him  properly  to  study  her  case.  Her  most  important 
symptom  was  anemia.  She  was  well,  up  to  the  time  of  her 
marriage  at  eighteen.  She  was  now  the  mother  of  six  chil- 
dren. For  the  past  ten  years  she  had  been  in  a  gradual  decline, 
growing  more  feeble  and  incompetent  for  her  housework, 
negligent  of  her  children,  the  victim  of  frequent  headaches, 
with  little  appetite,  moody  and  despondent.  Slight  exer- 
tion distressed  her;  various  kinds  of  food  brought  on  attacks 
of  nausea,  with  occasional  "bilious  vomiting";  she  had 
become  pale,  flabby  and  ineffective.  So  much  she  told  me, 
and  it  was  evident  that  she  regarded  the  history  as  complete ; 
obviously  her  numerous  physicians  had  learned  little  more. 
On  reflection,  however,  she  stated  that  during  the  past  year 
additional  signs  and  symptoms  had  appeared,  especially 
an  increasing  constipation,  frequency  of  micturition,  a  dis- 
tressing leucorrhea  and  an  unusual  flowing  at  the  time  of 
catamenia,  which  were  becoming  more  and  more  frequent. 
She  had  lost  some  fifteen  pounds  in  the  course  of  five 
years. 

I  found  Mrs.  Perkins  to  be  a  large,  stolid,  weary-looking 
individual,  decidedly  shabby  and  down-at-heel,  although 
her  circumstances  did  not  warrant  neglect  of  the  toilet. 
There  was  no  peculiarity  about  her  chest;  her  heart  was  not 
in  any  way  abnormal;  her  abdomen  was  large  and  flabby 
and  the  right  kidney  was  movable,  though  there  was  little 
evidence  of  other  abdominal  ptosis;  the  pelvic  outlet  was 
relaxed  and  there  was  a  slight  cystocele  and  a  rectocele; 
the  uterus,  while  retroverted  in  the  second  degree,  was 
freely  movable,  its  shape  not  peculiar,  its  size  that  of  a  large 
closed  fist ;  the  cervix  was  torn  and  bled  easily.^ 

^  In  this  case,  again,  the  diagnosis  is  not  so  obvious  as 
it  appears.  There  was  undoubtedly  a  myoma  present, 
but  it  is  hard  to  see  just  why  a  small  myoma  of  the  uterus 


.276  SURGICAL   PROBLEMS. 

should  have  caused  the  long  train  of  symptoms  which  had 
afflicted  the  patient  for  ten  years. 

Two  days  later  I  operated  on  Mrs.  Perkins,  removing  the 
uterus  above  the  cervix,  through  an  abdominal  incision. 
The  tumor  proved  to  be  a  large  submucous  myoma.  The 
wound  healed  kindly,  and  within  sixteen  days  the  patient 
was  walking  about.  A  month  after  the  operation  she  felt 
greatly  improved,  from  the  long  rest  in  bed  and  from  hospi- 
tal care.  When  she  began  to  go  about  more  actively,  how- 
ever, sundry  indefinite  pains  arose,  finally  centering  in 
severe  pain  near  the  upper  angle  of  the  incision  whenever 
she  stood  for  more  than  five  or  ten  minutes.  It  was  obvious 
to  me  then,  on  palpating  the  abdomen,  that  the  abdominal 
contents  were  extremely  relaxed,  the  organs  much  out  of 
place,  and  that  the  standing  posture  probably  caused  a 
dragging  of  some  slight  adhesion  on  the  abdominal  incision. 
A  week  later  all  the  symptoms  of  distress  had  increased  and 
the  old  condition  of  wretched  invalidism  was  rapidly  return- 
ing. Somewhat  half-heartedly,  and  in  order  to  relieve  the 
condition  as  far  as  I  could,  I  had  this  patient  also  fitted  with 
a  broad  abdominal  support,  giving  the  lift  entirely  from 
below  the  iliac  crests.  Immediate  benefit  to  the  symptoms 
resulted;  Mrs.  Perkins  has  been  wearing  such  a  support 
now  for  more  than  two  years,  and  declares  herself  to  be 
practically  well. 


ABDOMINAL.  277 

Case  85.  Miss  Flora  Arrowsmith,  who  gave  herself 
out  as  a  trained  nurse,  twenty-four  years  old,  came  with 
a  mysterious  manner  into  my  office  late  in  the  evening  of 
the  26th  of  April,  1910.  Before  I  could  get  at  the  nature 
of  her  difficulty,  she  told  me  a  long  story  about  her  training 
and  her  nursing  capacity.  She  appeared  as  a  bright,  attrac- 
tive young  person,  with  an  excellent  opinion  of  her  own  good 
looks,  an  opinion  which  I  came  to  believe  subsequently 
entered  largely  into  her  problem.  The  symptom  which 
she  finally  disclosed  was  severe  backache,  which  she  stated 
was  persistent  and  had  lasted  for  three  years,  accompanied 
frequently  by  pain  low  in  the  pelvis,  greatly  aggravated  by 
catamenia.  I  could  learn  nothing  important  from  her  previ- 
ous history.  She  stated  that  three  months  before  I  saw  her, 
when  in  New  York  City,  she  consulted  a  prominent  surgeon, 
who  gave  her  an  ether  examination  and  found  a  large  myoma 
of  the  uterus.  No  further  treatment  or  operation  was  carried 
out  at  that  time,  as  the  patient  was  then  averse  to  hysterec- 
tomy. She  informed  me  that  now,  however,  she  had 
determined  on  hysterectomy  and  wished  it  done  at  once.^ 
Miss  Arrowsmith  stated  further  that  she  herself  could  often 
feel  the  tumor  above  the  pubes,  and  that  the  constant  back- 
ache interfered  seriously  with  her  work  as  a  nurse.  She 
represented  herself  as  drifting  rapidly  into  a  chronic  in- 
validism. 

I  was  not  altogether  satisfied  with  the  patient's  story, 
and  thought  it  best  to  send  her  to  the  Massachusetts  General 
Hospital,  which  she  entered  on  the  following  day.  At  the 
hospital  I  examined  her.  She  was  a  vigorous,  healthy- 
looking  girl,  well  developed,  tall  and  robust.  Before  the 
examination  she  supplemented  her  previous  statements 
by  adding  a  detail  which  my  questioning  probably  had  sug- 
gested, namely,  that  since  seeing  me  the  night  previous 
she  had  had  a  depleting  hemorrhage  from  the  uterus.  I 
could  find  nothing  abnormal  on  palpating  the  abdomen. 
On  bimanual  examination  of  the  pelvis  I  discovered  a  lax 
and  easily  entered  vagina  and  a  uterus  not  enlarged,  but 
retroverted  to  the  third  degree.  Palpation  of  the  fundus 
through  the  rectum  appeared  to  cause  her  great  pain,  simi- 


278  SURGICAL    PROBLEMS. 

lar  to    the    pain    she    frequently    experienced    deep    in    the 
pelvis. 

The  patient  was  then  prepared  for  an  ether  examination 
and  operation  the  next  day.  Under  ether  I  confirmed  my 
previous  finding,  and  discovered  a  small,  retroverted  uterus, 
with  some  slight  evidence  of  uterine  catarrh.  I  dilated  the 
canal  and  curetted  the  uterus.  I  then  opened  the  abdomen 
by  a  transverse  incision  above  the  pubes,  lifted  up  the  small 
normal-appearing  uterus  and  suspended  it  by  the  round 
ligaments  drawn  over  the  recti  muscles.  There  was  no  sign 
of  a  tumor  anywhere  in  the  pelvis.  A  large,  injected  appen- 
dix was  removed  and  the  wound  was  closed  without  drainage. 
The  patient  recovered  promptly,  made  no  comment  on 
the  simple  nature  of  the  operation  performed,  and  within 
three  weeks  went  cheerfully  about  her  work,  apparently 
satisfied  with  her  condition.^ 

^  The  reader  will  observe  that  of  the  usual  signs  of  large 
uterine  tumor  the  only  one  present  here  was  pelvic  pain. 
There  was  no  hemorrhage,  nor  was  there  interference  with 
the  functions  of  rectum  or  bladder. 

^  This  case,  with  its  associated  suggestion  of  malingering, 
has  somewhat  puzzled  me,  and  I  am  still  at  a  loss  to  under- 
stand what  the  patient's  purpose  could  have  been  when  she 
informed  me  that  she  had  a  large  tumor  of  the  uterus  and 
asked  for  a  hysterectomy.  She  was  not  pregnant,  nor 
was  there  any  evidence  of  previous  pregnancy.  She  hinted 
at  an  engagement  and  impending  marriage,  but  that  could 
scarcely  account  for  her  desire  to  cripple  her  organs.  The 
story  of  consulting  a  New  York  surgeon  may  have  been 
entirely  false;  certainly  her  report  of  his  findings  was  false. 
It  may  be  that  she  had  a  morbid  curiosity  to  experience 
a  severe  surgical  operation,  though  such  a  curiosity  in  a 
trained  nurse  seems  improbable.  My  readers  are  at  liberty 
to  form  their  own  hypotheses.  She  is  still  at  her  work  as. 
a  nurse,  and  is  said  to  give  satisfaction  to  her  patients. 


ABDOMINAL.  279 

Case  86.  During  the  summer  of  1910  I  was  consulted 
a  number  of  times  by  an  old  classmate,  a  busy  manufacturer, 
Mr.  R.  W.  Rand,  of  Albany,  who  was  much  troubled  about 
the  physical  condition  of  his  wife.  He  told  me  that  she  was 
forty-one  years  of  age  and  that  they  had  been  married  twenty 
years.  She  had  never  been  pregnant  and  there  seemed  little 
probability  of  her  becoming  so.  Her  physician,  a  man  well 
known  to  me  and  highly  esteemed,  had  advised  his  discuss- 
ing her  situation  with  me.  Her  previous  history  was  stormy. 
Shortly  after  their  marriage  Mrs.  Rand  became  extremely 
despondent,  and  appears  to  have  gone  through  a  course  of 
melancholia,  for  which  at  one  time  it  seemed  best  to  confine 
her  in  a  sanatorium.  In  the  course  of  a  year  she  recovered 
her  mental  balance,  however,  and  returned  home.  She  was 
a  brilliant,  erratic,  interesting  person,  keenly  alive  to  her  hus- 
band's advancement  in  life,  and  active  at  the  same  time 
in  the  promotion  of  good  works,  especially  local  charities, 
hospitals  and  social  settlements.  Five  years  after  her  mar- 
riage she  developed  an  ovarian  tumor,  which  was  removed, 
without  subsequent  ill  effects.  Nevertheless,  she  was  said 
always  to  have  behaved  "  queerly,"  and  once  or  twice  in 
the  course  of  ten  years  to  have  threatened  suicide,  although 
there  did  not  seem  to  have  been  any  actual  mental  aberra- 
tion, according  to  the  opinion  of  a  competent  alienist.  For 
some  five  years  she  had  suffered  from  an  obstinate  dyspepsia, 
associated  with  recurring  frontal  headaches,  which  were  said 
to  be  of  extreme  severity.  She  suffered  from  an  obstinate 
form  of  chronic  constipation  also  and  from  irregular  and 
painful  menstruation,  at  which  times  her  "  queerness  " 
and  excitability  were  greatly  increased.  Mr.  Rand  informed 
me  that  things  had  come  to  a  crisis  about  three  weeks  before, 
when  she  broke  down  helplessly,  took  to  her  bed,  and,  in 
addition  to  her  other  sufferings,  was  distressed  by  a  severe 
tonsillitis  and  a  mysterious  skin  eruption.  One  w^eek  pre- 
viously she  was  seen  by  a  New  York  internist,  who  could 
make  no  diagnosis  of  her  disturbance  beyond  recognizing 
the  extremely  feeble  general  condition.  Her  blood  and  urine 
were  essentially  normal.  During  the  past  three  weeks  she 
had  been  in  bed.     A  further  statement  was  made  that  for 


280  SURGICAL    PROBLEMS. 

some  two  years  she  had  suffered  from  severe  left-sided  sci- 
atica. Through  all  this  period  she  had  not  lost  weight  per- 
ceptibly and  her  appetite  was  fair.  The  general  suggestion 
was  made  that  she  was  a  woman  who  exaggerated  her  symp- 
toms and  preferred  a  rather  semi-invalid  life.^ 

Urged  by  Mr.  Rand,  I  went  over  to  Albany  and  examined 
his  wife.  I  found  her  to  be  a  tall  woman  of  medium  build, 
in  young  middle  age,  smiling  cheerfully  as  she  lay  in  bed, 
but  complaining  of  a  persistent  pain  in  the  left  hip,  which 
she  called  sciatica.  She  was  somewhat  pallid,  but  extremely 
intelligent  and  sprightly  in  conversation.  The  chest  ex- 
amination was  negative,  except  that  the  heart  sounds  were 
somewhat  feeble.  The  eyes  were  apparently  normal;  there 
was  nothing  in  the  neck  to  suggest  goiter;  there  was  no  tremor 
of  the  extremities.  The  pulse  was  74,  temperature  98.4°, 
respirations  18.  She  made  no  further  complaint,  except 
that  she  was  especially  troubled  at  night  by  the  pains  I  have 
described.  The  abdomen  I  did  not  find  peculiar  until  I  came 
to  the  region  below  the  navel,  where  there  was  to  be  felt,  above 
the  pubes,  a  mass  about  the  size  of  a  child's  head,  situated 
mainly  on  the  left, —  nodular,  irregular,  hard,  movable  and 
apparently  connected  with  the  uterus.  It  was  not  painful 
or  tender,  but  resistant,  and  suggested  a  solid  uterine  tumor. 
The  patient  then  admitted  that  for  some  two  years  pre- 
viously she  had  flowed  excessively  at  her  periods,  but  had 
thought  little  of  the  matter.^ 

1  The  leading  feature  in  Mrs.  Rand's  case  seemed  to  be 
mental  and  nervous  disturbance,  rather  than  physical,  yet 
we  must  look  for  and  eliminate  physical  disorders,  so  far 
as  possible,  in  all  such  cases.  I  was  struck  particularly 
by  the  fact  that  she  had  had  removed  a  large  ovarian  cyst, 
an  event  which  would  have  impressed  any  surgeon.  We  are 
familiar  with  the  fact  that  growths  associated  with  the  pel- 
vic organs  are  often  multiple,  and  that  ovarian  cysts  may 
exist  with  tumors  of  the  uterus  and  its  adnexa. 

^  These  findings  seemed  to  bear  out  the  previous  suggestion, 
not  hitherto  made  either  by  alienists  or  internists,  that  some 
pelvic  disturbance  might  lie  at  the  bottom  of  her  whole  course 
of  invalidism.  So  far  as  I  could  judge,  the  tumor  had  been  of 
slow  growth  and  might  well  have  existed  for  ten  or  more  years. 


ABDOMINAL.  251 

Accordingly,  I  decided  on  the  operation  of  hysterectomy, 
and  sent  Mrs.  Rand  to  a  hospital.  In  this  case  the  psychic 
disturbance  was  so  marked  that  I  judged  it  wise  to  give  that 
element  in  the  case  unusual  consideration.  Although  the 
patient  accepted  cheerfully  the  prospect  of  an  operation, 
she  was  convinced  that  she  would  not  recover,  and  she 
made  all  arrangements  for  her  own  demise  and  the  subsequent 
funeral.  In  spite  of  her  forced  cheerfulness,  moreover, 
it  was  obvious  that  she  was  excessively  apprehensive.  I 
could  not  well  "  steal  away  "  the  growth,  as  I  have  sometimes 
done  in  cases  of  Graves'  disease,  but  I  endeavored  in  every 
way  possible  to  bring  her  to  the  operation  with  confidence. 
The  excellence  of  her  own  physical  condition  was  dwelt  upon, 
the  dangers  of  the  operation  were  minimized,  abundance 
of  sleep  by  bromides  was  secured,  and  an  extremely  care- 
ful and  tactful  anesthetist  was  engaged  to  give  the  anesthetic. 
On  the  morning  of  the  operation  the  anesthetist  visited  the 
patient  early,  ordered  morphin  and  scopolamin,  and  induced 
anesthesia  at  the  proper  time  with  nitrous  oxide  and  oxygen. 
When  the  anesthetic  was  given  Mrs.  Rand  was  practically 
asleep  and  seemed  unaware  of  the  cone  over  her  face.  Her 
pulse  was  90  at  the  beginning  of  the  inhalation,  and  by  the 
time  the  operation  was  over  it  had  fallen  to  86. 

On  opening  the  abdomen  I  disclosed  a  tumor  such  as  the 
previous  examination  had  indicated,  a  fibromyoma  of  the 
uterus,  intramural  and  involving  the  whole  organ.  The  right 
ovary  also  was  involved.  It  lay  close  behind  the  uterus  and 
was  the  size  of  a  large  grapefruit;  it  was  the  seat  of  a  fi- 
broid growth.  I  was  compelled,  therefore,  to  remove  not 
only  the  uterus,  above  the  cervix,  but  the  ovary  also,  which 
left  the  patient  devoid  of  both  ovaries,  inasmuch  as  her  left 
ovary  had  been  removed  years  before.  The  stump  of  the 
cervix  was  carefully  covered  in  and  suspended  by  the  round 
and  broad  ligaments  in  the  usual  manner. 

Mrs.  Rand  made  an  excellent  recovery  from  the  anes- 
thetic, being  practically  herself  before  reaching  her  own  room. 
The  convalescence  thereafter  was  uneventful  and  in  the  course 
of  two  weeks  she  went  home.  She  has  remained  physi- 
cally well  ever  since. 


282  SURGICAL   PROBLEMS. 

Probably  the  most  interesting  feature  of  this  case  was  the 
psychic  condition  in  which  I  found  the  patient  and  the 
improvement  in  that  condition  induced,  presumably,  by 
the  operation.  From  having  been  a  neurotic  invalid,  Mrs. 
Rand  has  become  a  vigorous,  alert,  interested  person,  keenly 
sympathetic  in  her  relations  with  her  family,  logical  in  her 
views  of  life,  and  in  all  ways  a  far  more  useful  person  than 
at  any  time  since  her  marriage,  and  this  is  spite  of  the  fact 
that  she  has  now  been  deprived  of  both  ovaries,  a  calamity 
which  we  are  wont  to  deplore  in  persons  who  have  not  yet 
passed  the  menopause. 


THE  UTERUS. 

Case  87.  Late  one  afternoon  in  the  summer  of  1906  I 
was  summoned  hastily  by  a  physician  to  see  a  woman  with 
him  in  a  farmhouse  some  ten  miles  from  Boston,  He  informed 
me  by  telephone  that  the  patient  had  been  successfully 
delivered  of  a  healthy  girl  six  days  previously,  but  that  the 
uterus  had  never  properly  involuted,  that  there  was  still 
an  unnatural  amount  of  hemorrhage,  which  was  becoming 
extremely  foul,  that  the  abdomen  was  distended  and  that 
he  feared  the  onset  of  puerperal  septicemia. 

On  reaching  the  patient,  Mrs.  O'SuUivan,  I  found  her  to 
be  a  large,  vigorous,  hard-fisted  wife  of  a  farmer,  herself 
thirty-six  years  old  and  the  mother  of  six  children.  Except 
for  her  confinements,  she  had  always  been  well.  There  had 
been  no  miscarriages  nor  ill-health  between  pregnancies. 
The  story  of  her  last  confinement  was  peculiar.  Apparently 
labor  had  come  on  four  weeks  before  it  was  due,  though  the 
child  when  born  did  not  appear  premature.  Throughout 
her  pregnancy  she  had  more  or  less  flowing,  usually  at 
the  expected  monthly  period,  so  that  she  was  unable  to  de- 
termine precisely  the  beginning  of  the  pregnancy.  During 
the  pregnancy  she  became  unnaturally  large  and  "  carried 
the  child  very  high."  By  the  end  of  the  eighth  month  she 
was  extremely  uncomfortable  from  her  unnatural  size, 
and  on  consulting  her  physician  was  told  that  she  probably 
was  carrying  twins  or  triplets.  The  confinement  was  long 
and  tedious.  The  physician  was  unable  satisfactorily  to 
reach  the  presenting  part  until  twenty- four  hours  had  elapsed, 
when  he  succeeded  in  finding  a  foot,  which  he  brought  down. 
The  patient  was  then  etherized,  and  prolonged  traction  on 
the  foot  at  last  succeeded  in  delivering  a  living  infant.  With 
the  birth  of  the  child  the  uterus  appeared  to  retreat  high 
into  the  abdomen  and  to  remain  of  considerable  size.  At 
first  the  physician  thought  that  it  contained  another  fetus, 
but  on   more   careful   investigation   he   concluded   that   the 

283 


284  SURGICAL   PROBLEMS. 

Uterus  itself  was  the  seat  of  a  tumor.  Satisfied  with  having 
secured  a  Hving  infant,  he  expected  no  further  trouble, 
but  much  to  his  disappointment  the  confinement  was  followed 
by  considerable  hemorrhage,  by  greatly  increased  lochia 
and,  as  he  stated  to  me,  by  a  foul  lochial  discharge  after  the 
fifth  day.  At  the  same  time  the  uterine  tumor  remained.^ 
On  examining  Mrs.  O'SuUivan  I  found  her  to  be  in  a  criti- 
cal condition.  Her  temperature  was  104°;  it  had  been  103° 
that  morning  and  103°  the  previous  night.  Her  pulse  was 
pounding  out  no.  The  abdomen  was  much  distended,  every- 
where tympanitic  and  tender,  while  the  tenderness  above 
the  pubes  was  excessive.  Bimanually  I  made  out  readily  a 
mass,  evidently  the  uterus,  about  the  size  of  a  child's  head, 
nodular  and  hard,  except  at  the  center,  where  there  was  a 
suspicious  doughy  feel.  The  lochial  discharge,  as  stated, 
was  extremely  offensive  and  abundant.  On  this  evidence 
I  made  the  diagnosis  of  sloughing  fibroid  of  the  uterus, 
following  delivery.  2 

1  The  mechanics  of  delivery  in  the  face  of  an  obstructing 
myoma  of  the  uterus,  which  was  here^  undoubtedly  present, 
are  well  known.  It  is  often  astonishing  to  observe  how  a 
myomatous  mass  almost  filling  the  pelvis  will  ride  up  into 
the  abdomen  during  labor,  and  will  give  free  passage  to  the 
advancing  fetus.  Undoubtedly  this  had  occurred  in  the 
present  case. 

2  A  pregnant  uterus  the  site  of  a  fibromyoma  is  dangerous. 
A  myomatous  growth  in  the  uterus  is  wont  to  enlarge  rapidly 
during  pregnancy,  owing  to  the  vastly  increased  blood  supply 
during  those  months.  After  delivery,  however,  and  with 
the  attempts  on  the  part  of  the  organ  to  involute,  the  blood 
supply  may  be  in  great  measure  cut  off  from  the  tumor, 
so  that  it  not  infrequently  happens  that  necrosis  results, 
and  a  dead,  sloughing  fibroid  takes  the  place  of  the  actively 
growing  mass.  Rarely  such  a  sloughing  fibroid  may  be  ex- 
pelled by  the  uterus  itself,  but  this  can  happen  only  in  the 
case  of  submucous  growths,  or  much  more  rarely  in  the  case 
of  well-isolated  intramural  growths. 

I  called  an  ambulance  and  sent  Mrs.  O'Sullivan  to  a  Boston 
hospital,  where  I  saw  her  some  two  hours  later.  I  operated 
at  once,  though  in  the  face  of  the  gravest  peril  to  the  patient. 


UTERUS.  285 

Operation,  however,  was  the  only  possible  resource.  The 
condition  found  bore  out  our  previous  understanding.  The 
uterus  itself  was  in  a  condition  of  subinvolution,  but  springing 
from  its  right  anterior  aspect,  and  attached  to  it  by  a  broad 
pedicle,  was  an  engorged  mass  the  size  of  a  child's  head, 
evidently  in  a  state  of  advanced  necrosis.  I  was  somewhat 
relieved  to  find  that  hysterectomy  was  needless.  By  care- 
fully packing  off  the  uterus  with  gauze  and  bringing  it 
outside  the  abdominal  cavity,  I  was  able  to  throw  a  couple 
of  ligatures  about  the  pedicle  of  the  tumor  and  to  amputate 
it  successfully,  with  little  loss  of  blood.  All  necrotic  tissue 
was  removed  and  the  wounded  uterus  was  carefully  repaired. 
It  was  then  returned  to  the  pelvis  and  was  covered  with  a 
protecting  arrangement  of  gauze  drains. 

The  patient  rallied  promptly  and  recovered.  I  presume 
her  excellent  previous  health  and  her  unusual  strength  of 
constitution  played  a  great  part  in  the  fight.  A  week  after 
the  operation  all  drains  were  removed,  and  in  the  course 
of  three  weeks  she  was  up  and  about,  and  went  home  in  con- 
fident health,  assuring  me  to  the  last  that  she  would  have  no 
more  babies.  I  am  told  that  she  has  clung  to  her  resolution 
and  remains  the  mother  of  seven  children  onlv= 


Fig.   12.     Case 


Note  buckling  of  ascending  colon,  with  hepatic  flexure  below  iliac  crest ;  transverse 
colon  in  pelvis,  kinked  splenic  flexure  high,  with  descending  colon  lying  against  transverse 
colon  ;  sigmoid  in  normal  position. 


INTESTINAL  OBSTRUCTION. 

Case  88.  Selma  Rodovsky  at  the  age  of  forty-one  knew 
no  English,  for  she  had  lived  in  this  country  but  six  months 
and  before  leaving  her  native  Poland  was  unfamiliar  with 
any  language  but  her  own.  On  the  5th  of  January,  191 1, 
she  entered  the  Massachusetts  General  Hospital,  when, 
through  an  interpreter,  we  extracted  from  her  a  long  and 
melancholy  story.  She  was  sent  to  the  hospital  for  acute 
intestinal  obstruction.  She  stated  that  she  had  been  married 
twenty  years.  In  her  girlhood  she  was  an  invalid,  the  vic- 
tim of  frequent  headaches,  attacks  of  indefinite  abdominal 
pain  and  obstinate  constipation.  She  was  undersized  as 
a  girl,  and  even  at  forty-one  appeared  as  undeveloped  as 
a  child  of  fourteen.  At  twenty-one  she  married,  but  was 
never  pregnant.  The  wife  of  a  laboring  man,  she  herself 
was  accustomed  to  hardship,  and  was  worn  and  frail.  Some 
fifteen  years  before  I  saw  her  she  had  suffered  from  recurring 
attacks  of  acute  abdominal  pain,  located  mainly  in  the  ap- 
pendix region,  but  she  had  never  been  operated  upon.  It 
seemed  fair  to  assume  that  this  disturbance  was  appendicitis. 
For  the  past  ten  years  her  digestive  disorders  had  increased. 
She  had  little  appetite,  was  always  under-nourished,  vomited 
occasionally,  though  not  in  large  amounts,  but  suffered 
especially  from  frequent  attacks  of  what  appeared  to  be 
intestinal  obstruction.^  The  nature  of  the  obstruction  in 
her  case  was  indefinite,  but  the  symptoms  were  clear. 
She  stated  that  after  a  long  course  of  increasing  constipa- 
tion her  bowels  ceased  to  move,  usually  for  some  days;  that 
she  then  became  distended,  vomited  frequently,  and  could 
often  feel  a  mass  in  some  portion  of  the  abdomen,  usually 
in  the  right  side.  There  was  rarely  any  fever,  but  there 
was  profound  prostration.  Such  attacks  passed  off  eventu- 
ally, after  vigorous  dosing  with  cathartics,  under  the  direc- 
tion of  a  physician.  Her  last  previous  attack  occurred  in 
October,  1910. 

287 


288  SURGICAL   PROBLEMS. 

On  entering  the  hospital,  Mrs.  Rodovsky  was  seen  by  the 
house  surgeon,  who  examined  her  carefully.  She  was  a  slight, 
frail  woman,  in  early  middle  age,  four  feet  ten  inches  in  height, 
and  weighing  one  hundred  pounds.  She  was  patient,  inar- 
ticulate and  extremely  feeble.  Her  pulse  was  no  and  her 
temperature  normal.  While  in  other  respects  the  examination 
was  negative,  the  abdomen  was  conspicuous.  It  was  some- 
what distended  and  tympanitic,  tender  throughout,  but 
especially  tender  along  the  right  costal  margin,  where  a  mass 
the  size  of  a  large  sausage  could  be  felt.  This  was  movable 
and  seemed  doughy  to  the  feel.  It  could  be  pushed  about 
readily,  even  as  far  as  the  navel.  There  was  no  enlargement 
of  the  liver,  nor  was  there  positive  evidence  of  metastasis. 
Assuming  that  the  tumor  was  a  fecal  impaction  at  the 
hepatic  flexure,  the  house  surgeon  ordered  large  oil  enemata, 
which  eventually  acted  to  bring  away  the  mass.  This  was 
followed  up  by  mild  purgatives,  which  cleared  out  the 
patient's  bowels  and  left  her  abdomen  flat  and  relatively 
painless.  The  whole  experience  lasted  some  four  days, 
and  seemed  to  be  extremely  distressing.  The  immediate 
diagnosis  obviously  was  fecal  impaction,  but  the  cause  of 
the  impaction  remained  to  be  discovered.  In  order  to  as- 
certain this,  the  patient  was  given  a  bismuth  meal  and  was 
submitted  to  an  x-ray  examination.  This  examination 
was  interesting.  It  showed  the  stomach  in  a  normal  position 
but  the  colon  much  displaced,  the  cecum  loose  and  far 
down  in  the  pelvis,  the  ascending  colon  crumpled  and  pro- 
lapsed, the  transverse  colon  running  from  the  pubes  to  the 
splenic  flexure,  which  was  held  well  up  in  the  normal  posi- 
tion. The  bismuth  failed  to  penetrate  deeply  the  trans- 
verse colon,  save  for  a  thin,  ribbonlike  line,  while  the 
descending  colon  showed  not  at  all. 

Here  was  a  case  of  a  hard-working  woman,  the  victim  of 
recurring  incapacity,  for  whom  it  seemed  best  to  do  some 
radical  operation.  Accordingly,  a  few  days  later  I  explored 
the  abdomen,  and  found  the  large  intestine  in  the  position 
indicated  by  the  x-rays,  the  omentum  being  rolled  up  and 
of  insignificant  dimensions  and  lying  deep  in  the  pelvis 
beneath  the  colon.    It  seemed  impossible  to  establish  a  proper 


INTESTINAL   OBSTRUCTION.  289 

intestinal  tube  approximating  even  to  the  normal.  Accord- 
ingly, I  severed  the  ileum  from  the  cecum,  and  implanted 
it  in  the  upper  portion  of  the  sigmoid  flexure.  I  then  rap- 
idly removed  the  whole  colon,  the  ascending  and  trans- 
verse portions  without  difficulty,  and  the  descending  portion 
as  far  as  the  sigmoid  stoma,  where  I  cut  away  the  descending 
colon  and  closed  the  sigmoid  above  the  new  stoma.  The 
patient  was  thus  left  practically  without  a  colon,  save  for 
the  sigmoid. 

An  extremely  interesting  observation  in  connection  with 
this  operation  —  an  observation  made  many  times  by  other 
operators  —  is  the  slight  amount  of  shock  suffered  by  the  pa- 
tient during  the  removal  of  the  colon.  Before  taking  the 
anesthetic  her  feeble  pulse  registered  80;  at  the  end  of  the 
operation  it  was  76,  and  of  fair  quality.  She  rallied  satis- 
factorily and  went  on  to  an  uncomplicated  convalescence. 
Three  days  after  the  operation  her  bowels  moved  naturally 
and  there  was  no  diarrhea.  Since  that  time  the  condition 
of  the  bowels  has  been  satisfactory,  with  one  or  two  daily 
movements.  She  has  gained  in  weight,  is  more  vigorous  than 
for  a  long  time,  and  expresses  the  greatest  satisfaction 
with  what  we  have  done  to  relieve  her.^ 

1  Intestinal  obstruction  in  a  woman  between  thirty  and 
forty  may  be  due  to  acute  or  to  chronic  disease,  but  it  Is 
most  commonly  due  to  acute  disease  of  an  Inflammatory 
or  mechanical  nature,  such  as  appendicitis,  Intussusception, 
volvulus  and  the  like.  Chronic  intestinal  obstruction  In 
relatively  young  persons  is  rare.  When  present,  we  think 
of  obstruction  by  bands,  by  adhesions  due  to  some  inflam- 
matory process,  possibly  tuberculous  peritonitis,  and,  more 
rarely,  to  malignant  disease.  There  are,  of  course,  other  and 
less  frequent  causes. 

2  Extirpation  of  the  colon  for  these  extreme  degrees  of 
ptosis  infrequently  is  necessary  or  justifiable.  Usually  a 
proper  corset-belt  will  improve  the  symptoms.  Commonly 
when  an  operation  is  necessary,  the  operation  may  be  limited 
to  a  short-circuiting  of  the  large  intestine  and  ^  leaving  it 
in  place, —  so  that  what  we  do  is  merely  an  implanting 
of  the  Ileum  Into  the  sigmoid.  I  have  on  two  occasions 
anastomosed  the  cecum  with  the  sigmoid,  cutting  off  no 
bowel  whatever.    This  operation,  however,  is  not  altogether 


290 


SURGICAL   PROBLEMS. 


satisfactory,  as  it  leaves  a  double  channel  for  the  fecal 
stream,  and  on  more  than  one  occasion  has  resulted  in  a 
partial  impaction  in  the  transverse  colon.  While  I  am  still 
skeptical  as  to  the  frequent  necessity  for  ablation  of  the  colon, 
I  believe  that  there  are  certain  desperate  cases  in  which  such 
ablation  must  be  the  only  remedy,  while  a  relatively  small 
experience  has  convinced  me  that  the  shock  of  the  operation 
is  much  less  than  is  removal  of  portions  of  the  colon  for 
malignant  disease. 


THE  PELVIS. 

Case  89.  Miss  Violet  Bauer,  an  athletic  spinster  of  forty- 
two,  had  a  large  estate  in  northern  Pennsylvania,  where 
she  lived  without  care,  save  for  the  health  of  her  horses 
and  the  fruitage  of  her  greenhouses.  She  was  accustomed 
to  spend  some  weeks  annually  in  eastern  Massachusetts, 
and  had  consulted  me  occasionally  for  many  years  when  she 
came  seriously  to  face  a  surgical  operation,  in  June,  1905. 
Her  physical  and  mental  habits  may  have  had  some  bearing 
on  her  ailment. 

She  was  a  tall,  vigorous,  muscular,  active  person  from  child- 
hood, given  to  long  rides  across  country,  to  following  the 
hounds,  to  hours  daily  on  the  tennis  court,  and  to  the  best 
sort  of  rough,  wholesome,  out-of-doors  life.  At  forty-two 
she  seemed  quite  up  to  the  needs  of  this  career,  although 
she  came  of  a  somewhat  delicate  and  languid  stock.  She 
had  suffered  from  measles  and  scarlatina  in  childhood; 
at  twenty-nine  she  had  a  long  course  of  typhoid  fever,  with 
a  serious  relapse,  the  whole  running  over  some  six  months. 
Since  childhood  she  was  given  to  joint  pains  in  cold  weather 
and  to  frequent  attacks  of  what  had  been  called  neuritis, 
located  in  the  shoulders,  in  either  the  left  or  right  circumflex 
nerves.  She  threw  off  these  disturbances  slowly,  but  always 
returned  vigorously  to  her  usual  mode  of  life.  She  was  some- 
what dyspeptic,  could  take  little  wine  or  spirits  without 
subsequent  distress,  ate  sparingly  of  a  simple  diet,  and  suf- 
fered from  habitual  constipation.  When  she  consulted  me, 
on  the  17th  of  June,  1905,  she  told  me  that  for  five 
years  she  had  had  pain  at  the  menstrual  periods  —  pain 
increasing  with  time.  The  catamenia  also  had  become 
somewhat  irregular,  coming  on  every  twenty-six,  twenty- 
eight  or  thirty-two  days.  Of  late  the  pain  was  much  worse 
and  persisted  five  or  six  days  after  the  cessation  of  flow;  it  did 
not  precede  the  flow.  Often  there  was  a  distressing  sense  of 
pressure  in  the  rectum  during  the  continuance  of  the  pain.^ 

291 


292  SURGICAL    PROBLEMS. 

A  physical  examination  of  the  patient  was  not  altogether 
satisfactory.  She  was  the  alert,  active  woman  I  have  de- 
scribed, but  seemed  to  be  unusually  sensitive  to  any  pel- 
vic examination.  The  abdomen  was  flat  and  negative, 
except  for  persistent  tenderness  at  McBurney's  point, 
suggesting  either  a  chronic  appendicitis  or  the  frequent 
condition  of  prolapse  of  the  cecum,  which  is  so  often  con- 
founded with  appendicitis.  The  uterus  was  slightly  en- 
larged, retroverted  in  the  third  degree  and  tied  down.  There 
was  a  marked  endometritis.  There  was  also  a  small  mass, 
probably  the  right  ovary,  felt  in  the  right  cul-de-sac,  ten- 
der and  adherent.  In  view  of  these  findings,  I  advised  an 
exploratory  operation  and  setting  right  the  complicated 
disorders. 

For  more  than  six  months  the  patient  took  no  further 
steps  in  regard  to  her  pelvic  trouble.  On  February  26, 
1906,  she  called  on  me  again,  reporting  that  she  had  had 
occasional  attacks  of  excessive  right  ovarian  pain  between 
periods,  and  this  only  during  the  past  five  months.^  Up  to 
that  time  this  patient  had  dodged  the  question  of  opera- 
tion because  her  life  was  busy  and  interesting,  and  she 
was  unwilling  to  postpone  her  numerous  engagements. 
Now,  however,  the  season  of  Lent  was  approaching,  her 
country  house  was  regarded  as  somewhat  remote  by  most 
of  her  friends,  and  she  concluded  that  the  time  had  come 
for  an  operation.  She  therefore  arranged  with  me  to  go  to 
her  place  to  operate  on  the  nth  of  the  following  March. 

I  have  often  protested,  and  I  protest  again,  against 
the  common  habit  of  surgeons  of  performing  serious, 
major  operations  in  remote  country  places  and  then  leaving 
their  patients  to  fight  their  way  back  to  health.  I  believe 
strongly  in  the  value  of  the  surgeon's  personal  care  during 
convalescence,  or  at  least  in  his  keeping  in  close  touch 
with  the  local  physician  in  charge.  In  this  case  close 
supervision  and  the  personal  following  of  the  case  on  my 
part  were  impossible,  but  I  was  over-persuaded  by  the  pa- 
tient to  perform  the  operation  at  her  own  residence.  At 
least,  she  was  provided  with  two  of  my  best  and  most 
experienced  nurses. 


THE    PELVIS.  293 

The  findings  at  the  operation  were  in  many  ways  interest- 
ing. After  curetting  the  uterus,  I  opened  the  abdominal 
cavity  by  a  transverse  Pfannensteil  incision,  which  in  this 
case  seemed  particularly  appropriate,  as  the  patient  was 
an  unmarried  woman  and  the  organs  to  be  handled  did  not 
include  any  large  masses.  The  uterus  was  enlarged  to  the 
size  of  a  man's  fist,  and  was  tied  down  firmly,  with  its  fun- 
dus in  the  sacrum.  The  right  ovary  was  the  seat  of  an  en- 
chondroma  and  was  the  size  of  a  large  English  walnut; 
it  was  adherent  closely  and  posteriorly  to  the  uterus.  A 
portion  of  this  right  ovary  contained  a  collection  of  blood, 
filling  a  cyst  as  large  as  a  hen's  egg.  The  same  hemorrhage 
which  had  distended  the  ovary  had  extended  also  into  the 
broad  ligament,  and  was  obviously  due  to  the  rupture  of 
small  branches  of  the  right  ovarian  artery.  As  a  result, 
the  broad  ligament  for  an  area  as  large  as  a  child's  palm 
was  distended  with  blood  clots.  Throughout  the  right  broad 
ligament  and  at  two  points  in  the  left  broad  ligament  were 
old  scars,  suggesting  obviously  similar  previous  hemorrhages. 
These  hemorrhages  appeared  to  account  for  the  excru- 
ciating and  prolonged  pain  which  the  patient  had  suffered 
after  a  number  of  her  catamenial  periods.  It  is  an  interest- 
ing and  somewhat  unusual  condition.  I  have  seen  it  much 
more  extensive  in  another  case,  in  which  a  large  area  of  the 
peritoneum  was  distended  and  banked  up  by  blood,  which 
there  formed  an  ominous  looking  hematoma,  half  as  large 
as  a  child's  head.  Fortunately,  in  the  case  of  Miss  Bauer 
the  hemorrhages  were  slight.  A  six-inch  coil  of  the  ileum 
also  was  closely  adherent  to  the  uterus  and  the  diseased 
ovary.  The  appendix  was  injected,  kinked  and  thickened, 
and  lay  behind  the  cecum,  which  hung  down  somewhat, 
with  an  unusually  long  mesentery.  The  left  tube  and  ovary 
appeared  to  be  normal.  The  gall  bladder,  stomach  and  other 
viscera  were  not  peculiar.  The  uterus  bore  upon  its  pos- 
terior surface  two  small  fibroids,  the  size  of  marbles.^ 


^  Pain  preceding  or  following  the  menstrual  period  may 
or  may  not  be  significant.  The  pain  preceding  the  flow 
is  frequently  referred  to  as  ovarian  pain,  ovarian  neuralgia. 


294  SURGICAL    PROBLEMS. 

etc.,  and  seems  to  be  associated  with  an  extensive  engorge- 
ment of  the  ovaries.  The  well-known  maneuver  of  cut- 
ting the  ovarian  nerves  is  curative  in  such  cases.  On  the 
other  hand,  pain  continuing  after  the  cessation  of  the  flow 
is  much  less  easily  explained.  In  a  number  of  cases  I  have 
found  such  pain  to  be  due  to  tubal  disease,  or  other  obstruc- 
tion high  in  the  generative  canal. 

^  Intermenstrual  pain  is  practically  always  due  to  unusual 
circulatory  activity,  localized  in  the  pelvis.  Sometimes 
such  pain  is  associated  with  intermenstrual  flowing,  some- 
tirnes  with  an  unusual  engorgement  of  the  pelvic  organs 
merely. 

"''  This  complication  of  disorders  was  much  more  extensive 
and  more  serious  in  pathological  appearance  than  the  patient's 
symptoms  had  seemed  to  warrant  our  expecting.  Doubtless 
her  vigorous  mode  of  life  and  correct  habits  enabled  her 
to  suppress  the  expression  of  pain  and  discomfort,  but  it 
seems  as  though  she  must  have  had  at  some  time  a  rather 
severe  pelvic  peritonitis,  the  origin  of  which  is  not  obvious. 
A  matting  of  the  uterus,  the  ileum,  one  tube  and  ovary, 
and  the  dense  adherence  of  these  structures  to  the  sacrum, 
are  our  evidence.  Certainly  the  case  is  unusual,  but  is  much 
more  hopeful  in  outlook  than  it  would  be  were  we  confronted 
with  the  diseased  organs  of  a  married  woman,  the  subject 
of  lacerations  and  of  possible  puerperal  infection. 

I  followed  the  obvious  indications  for  treatment;  broke 
up  the  adhesions  by  a  long  and  tiresome  dissection,  removed 
the  right  tube  and  ovary,  excised  the  blood  sacs  and  the  small 
fibroids,  removed  the  appendix,  and  suspended  the  uterus 
by  uniting  the  round  ligaments  In  front  of  the  recti  muscles. 
The  pelvis  was  left  dry.  The  operation  was  extremely 
tedious,  lasting  more  than  two  hours,  but  the  patient  was 
returned  to  her  bed  in  excellent  condition.  There  Is  nothing 
to  record  of  the  convalescence.  Miss  Bauer  was  up  and  about 
at  the  end  of  two  weeks,  and  at  the  end  of  three  months 
was  following  actively  her  usual  pastimes.  She  has  been  per- 
fectly well  since  the  operation,  and  especially  has  shown 
no  tendency  to  a  repetition  of  her  intermenstrual  attacks 
of  pain. 


I  THE    PELVIS.  295 

Case  90.  In  the  autumn  of  1907,  while  visiting  a  remote 
cottage  hospital  in  the  New  Hampshire  hills,  with  the  local 
physician  of  the  place,  I  was  asked  to  operate  upon  Miss 
Anna  Flaxman,  thirty-five  years  of  age,  who  had  made  a 
long  wagon  journey  that  morning  for  the  purpose  of  an 
examination  and  a  possible  operation.  Miss  Flaxman  was 
a  school-teacher  living  in  a  small  village  twelve  miles  from 
any  railway,  and  equally  far  from  a  physician.  The  daughter 
of  a  farmer,  she  had  grown  up  in  wholesome  surroundings, 
and  had  never  been  ill  until  the  age  of  sixteen.  At  that  time 
however,  she  lost  her  mother;  and  being  the  eldest  of  seven 
children  had  found  the  serious  responsibilities  of  house- 
keeping, and  the  farm,  thrown  upon  her  shoulders.  She 
seems  to  have  been  unequal  to  the  task  in  many  ways;  al- 
though intelligent,  and  zealous,  she  was  physically  ineffec- 
tive, and  broke  down  under  the  strain.  It  was  said  that  she 
broke  down  from  dyspepsia.  The  story  of  that  breakdown 
was  thought  to  be  significant.  Gradually  she  found  that 
she  could  eat  no  breakfast;  with  the  early  morning  risings 
between  four  and  five  she  had  frequent  attacks  of  nausea 
and  vomiting;  and  she  was  seldom  able  to  take  nourishment 
before  eleven  or  twelve  in  the  morning,  when  she  contented 
herself  with  a  bowl  of  hot  milk.  She  was  dizzy,  and  had  been 
known,  on  several  occasions  to  fall  in  a  '^  fit "  ;  towards  evening 
she  frequently  had  pain  in  the  epigastrium,  which  caused 
her  to  look  forward  eagerly  to  her  supper.  Supper,  always 
a  hearty  one,  relieved  her  pain  and  brought  a  sensation 
of  comfort  so  that  she  was  able  to  do  her  evening  work 
tranquilly.  She  went  to  bed  usually  between  eight  and  nine 
o'clock.  She  fell  into  a  troubled  sleep  at  once  on  going  to  bed, 
but  used  to  wake  up  between  twelve  and  one  in  the  morning 
with  a  recurrence  of  abdominal  pain.  After  much  experi- 
menting she  discovered  that  this  pain  was  relieved  by  drink- 
ing hot  milk,  so  that  it  was  her  custom  to  get  up  and  heat 
milk  regularly  in  the  middle  of  the  night.  This  distress, 
the  anxiety  for  her  health,  and  the  increasing  demands  of 
younger  brothers  and  sisters  finally  wore  her  down,  so  that 
the  physician  who  traveled  many  miles  to  see  her  advised 
her  spending  six  weeks  in  bed.     She  was  greatly  improved 


296  SURGICAL   PROBLEMS. 

by  rest  in  bed,  and  by  the  care  which  she  received;  but 
had  never  been  able  to  go  back  to  the  active,  hard  work 
of  farm  and  kitchen.  Her  father  was  able  to  send  her  to  a 
neighboring  normal  school  for  a  year,  and  at  the  age  of  eight- 
een she  began  the  life  of  a  country  district  school-teacher, 
which  she  had  followed  for  some  seventeen  years  when  I 
saw  her.  During  this  period  of  seventeen  years  she  was  not 
altogether  free  from  her  old  physical  disturbances;  but  the 
nature  of  her  ailments  had  changed  somewhat.  She  still 
suffered  from  occasional  attacks  of  nausea  and  from  indiges- 
tion several  hours  after  eating,  —  pain  relieved  by  food, — 
but  there  was  in  addition  more  headache,  more  blurring  of 
vision,  and  on  two  occasions  distinct  attacks  of  jaundice. 
Moreover,  her  bowels  became  troublesome,  until  she  finally 
fell  into  a  pronounced  habit  of  chronic  constipation.  In  other 
respects  her  physical  history  was  not  peculiar;  she  had  suf- 
fered from  the  usual  winter  colds  of  the  country,  from  ir- 
regular catamenia,  from  the  weariness  of  long  hours  and 
improper  food,  and  from  the  discouraging  circumstances  of 
a  rather  dreary  existence. 

When  I  met  Miss  Flaxman  at  the  cottage  hospital  on  Oc- 
tober 24,  1907,  she  appeared  as  a  simple,  tired  woman  of 
middle  age.  She  appeared  forty-five,  though  her  actual  age 
was  thirty-five.  She  was  tall  and  gaunt,  with  much  gray 
in  her  scanty  blonde  hair;  she  blinked  through  powerful 
glasses;  her  height  was  five  feet  five  inches;  her  weight 
a  hundred  and  five  pounds;  she  was  emaciated  and  debili- 
tated, with  long,  thin,  dry,  flaccid  hands.  The  patient  told 
me  her  story,  but  without  any  special  interest  or  enthusiasm ; 
she  had  told  it  before  without  benefit.  I  gathered  from  her 
words  that  she  had  never  been  properly  examined  by  any 
physician,  that  she  had  depended  largely,  for  her  medical 
advice,  on  the  old  ladies  of  her  community;  and  was  saturated 
with  patent  medicines.  At  first  glance,  and  on  observing 
the  patient's  bearing  and  mental  outlook,  it  appeared  that 
her  main  disturbance  was  probably  a  chronic  dyspepsia 
associated  with  a  prolapse  of  some  of  the  abdominal  organs. 
I  examined  her  with  some  care,  however,  and  was  interested 
to  find  that  above  the  diaphragm  she  was  everywhere  sound ; 


THE    PELVIS.  297 

there  was  no  sign  of  any  disturbance  with  the  lungs  or  heart. 
The  abdomen  was  flat,  but  nowhere  tender  until  I  came  to 
an  examination  of  the  lower  portion ;  there  was  the  usual  ten- 
derness in  the  region  of  the  appendix,  so  common  in  flabby 
persons;  while  deep  pressure  above  the  pubis  gave  her  a 
sensation  of  general  abdominal  distress  and  nausea.  It 
then  occurred  to  me  that  the  difficulty  was  probably  pelvic. 
On  making  a  careful  bimanual  examination  of  the  pelvis, 
I  was  interested  to  find  that  the  whole  pelvis  was  filled  by 
an  apparently  solid  tumor,  not  connected  with  the  uterus, 
so  far  as  I  could  judge,  and  apparently  about  the  size  of  a 
child's  head.  Toward  the  right  in  the  false  pelvis  and  near 
the  cecum  was  a  more  pronounced  tumor,  fixed,  tense,  ten- 
der, in  its  turn  also  about  the  size  of  a  child's  head.^ 

^  Gynecologists  long  ago  bade  the  profession  look  to  the 
pelvis  as  the  source  of  all  disease.  Our  revolt  against  this 
teaching  during  the  past  ten  years  has  perhaps  led  us  too 
much  to  disregard  the  pelvis.  Certainly  in  the  case  of  Miss 
Flaxman  pelvic  disease  had  never  been  considered.  Had  I 
been  asked  for  a  casual  diagnosis  and  without  examination, 
I  should  have  said  that  it  lay  between  duodenal  ulcer  — 
founding  my  opinion  upon  "  relief  by  food  "  —  and  entero- 
ptosis.  Pelvic  tumors  are  frequently  associated  with  ptosis 
however.  The  outline  of  the  tumor  in  this  case  suggested 
the  presence  of  a  normal  down-crowded  uterus  overridden 
by  two  solid  ovarian  tumors. 

The  patient  had  been  warned  of  possible  operation,  and 
came  to  the  hospital  prepared  for  that  event.  Accordingly 
she  was  anesthetized  at  once,  and  the  abdomen  opened  in 
the  median  line.  I  found  the  right-side  tumor  near  the  cecum 
to  be  a  densely  adherent,  strangulated  ovarian  cyst  with 
three  twists  in  its  pedicle;  apparently  the  strangulation 
had  occurred  within  a  few  hours  only,  for  the  cyst,  though 
black,  was  not  yet  necrotic;  it  was  extremely  tense.  On 
the  left  side  of  the  pelvis  was  another  tumor,  as  I  had  sus- 
pected, but  a  cyst  not  strangulated,  almost  equally  tense 
with  the  right-side  cyst.  I  removed  both  tumors  without 
trouble,  and  found  them  to  be  dermoids  containing  the 
usual  mass  of  detritus,  fat  and  hair.    I  removed  the  appendix 


298  SURGICAL   PROBLEMS. 

also,  which  was  slightly  adherent  to  the  right-side  cyst; 
and  completed  the  operation  by  suspending  the  uterus  by 
the  broad  ligaments.  Miss  Flaxman  did  not  do  very  well 
after  the  first  week;  she  had  some  fever,  and  a  fluctuating 
mass  developed  deep  in  the  pelvis.  On  the  13th  of  November 
I  again  visited  the  hospital,  and  found  the  patient  in  poor 
condition.  I  aspirated  the  pelvic  mass  by  vaginal  puncture 
and  cleaned  out  a  large  amount  of  pus  evidently  due  to  the 
infected  right  ovarian  cyst.  The  patient's  condition  im- 
proved at  once,  and  within  ten  days  she  left  cheerfully  for 
her  home.  I  have  heard  from  Miss  Flaxman  several  times 
during  the  past  three  years,  and  am  able  to  report  that  most 
of  her  severe  symptoms  are  greatly  relieved.  While  her 
appetite  is  still  capricious  and  her  headaches  occasionally 
troublesome,  the  pronounced  condition  of  invalidism  has 
entirely  disappeared,  and  she  is  able  to  do  her  work  with 
comfort  and  satisfaction. 


THE    PELVIS.  299 

Case  91.  Miss  Araminta  Jehrs,  thirty-one  years  of  age, 
was  referred  to  me  by  a  stomach  specialist  on  the  5th  of 
December,  1907.  She  was  an  assistant  librarian  in  a  large 
public  library,  and  appeared  as  an  intelligent,  wide-awake, 
person,  although  giving  a  somewhat  neurotic  history.  She 
informed  me  that  her  general  health  had  been  fair  until  eight 
months  previously,  when  her  stomach  began  to  grow  hard 
and  large.  Associated  with  the  hardening  of  her  stomach, 
she  was  greatly  troubled  with  dyspepsia  of  a  puzzling  kind, — 
an  idiosyncrasy  against  certain  forms  of  food,  especially 
roast  mutton  and  codfish,  both  of  which  caused  her  most 
intense  distress  until  she  was  able  to  vomit  them.  She  came 
of  German  parentage  and  lived  largely  on  German  cooking; 
sauerkraut  and  sausages  agreed  with  her,  as  did  the  most 
vigorous  forms  of  New  England  pastry.  She  was  a  great 
tea  drinker,  but  seemed  to  think  that  indulgence  in  tea  did 
not  affect  her  appetite  or  induce  digestive  disturbance. 
During  the  past  eight  months  she  had  become  somewhat 
morbid,  fretful  and  apprehensive.  One  grandmother  had  died 
in  an  insane  asylum,  and  she  herself  feared  a  similar  fate. 
She  stated  that  the  physician  who  referred  her  to  me  regarded 
her  case  as  one  of  pyloric  spasm,  and  had  treated  her  with 
large  doses  of  subcarbonate  of  bismuth  and  bicarbonate  of 
soda.  For  a  time  this  antacid  treatment  relieved  her,  but 
lately  she  had  become  worse. ^  In  addition  to  her  troublesome 
gastric  and  mental  symptoms,  the  patient  suffered  from 
an  obstinate  constipation  and  spoke  of  loss  of  weight  —  ten 
pounds  —  and  general  debility.  She  informed  me  further 
that  during  the  past  month  the  gastric  distress  had  in- 
creased, with  a  sense  of  nausea  and  gagging  three  or  four 
hours  after  all  food.  For  two  months,  her  catamenia,  which 
had  always  been  regular,  had  ceased, ^  The  urine  was 
reported  as  negative. 

The  patient  was  a  short,  well-developed  woman,  of  anx- 
ious appearance,  highly  intelligent  and  appreciative  of  our 
efforts  to  help  her.  The  chest  examination  was  negative. 
The  abdomen  showed  a  marked  protrusion  throughout; 
it  was  uniformly  enlarged,  smooth,  dull  on  percussion, 
non-fluctuant,  though  the  appearance  suggested  ascites.     On 


300  SURGICAL    PROBLEMS. 

careful  palpation  it  seemed  as  though  there  were  a  mass 
the  size  of  a  child's  head  in  the  region  of  the  navel.  This 
appeared  to  lie  in  the  midst  of  the  general  abdominal  dis- 
tention. Tympany  could  be  discovered  in  the  epigastrium 
and  low  in  the  flanks  only;  there  was  no  shifting  dullness 
as  the  patient  turned.  The  tumor  was  not  apparently  con- 
nected with  the  uterus.  Bimanual  examination  was  negative ; 
I  did  not  probe  the  uterus,  on  account  of  a  suspicion  of  preg- 
nancy. My  consultant's  note  stated  that  the  thought  of 
phantom  tumor  had  been  entertained.^ 

^  The  irregularity  of  gastric  symptoms  and  the  fact  that 
many  forms  of  food  caused  no  distress  is  misleading.  Asso- 
ciated with  the  gastric  hyperchlorhydria,  one  thinks  of 
either  gastric  or  duodenal  ulcer.  In  Miss  Jehrs'  case,  however, 
the  ordinary  symptoms  of  ulcer  were  lacking.  The  ingestion 
of  food  was  not  followed  by  pain,  either  immediate  or  delayed ; 
there  had  been  no  peculiar  vomiting,  and  the  physician's 
report  which  was  sent  to  me  showed  a  very  slight  degree 
of  hyperchlorhydria. 

2  Here  is  an  additional  group  of  symptoms,  extremely  sug- 
gestive to  an  experienced  practitioner, —  slight  loss  of  weight, 
enlargement  of  the  "  stomach,"  amenorrhea  and  nausea. 
One  can  hardly  escape  the  conviction,  or  at  least  the  thought, 
that  the  patient  may  be  in  the  second  month  of  pregnancy. 

^  A  marked,  uniform,  general  enlargement,  without  shift- 
ing dullness,  suggests  fluid,  probably  encapsulated,  as  from 
tuberculous  peritonitis  or  a  cyst;  the  isolated  hard  tumor 
near  the  navel  suggests  a  solid  tumor  of  the  ovary,  or  of  some 
other  organ;  as  though  we  were  dealing  here  with  a  mul- 
tiple process  and  not  a  single,  simple  growth. 

I  was  unable  to  give  Miss  Jehrs  a  definite  diagnosis,  but 
urged  her  strongly  to  have  an  operation  done,  in  order  to 
establish  the  diagnosis  and,  if  possible,  to  remove  the  disease. 
Accordingly,  she  entered  a  private  hospital,  where  I  operated 
two  days  later.  On  opening  the  abdomen  in  the  median  line, 
I  disclosed  a  large  cyst,  of  far  greater  extent  than  is  ordinarily 
seen  in  these  days.  It  reminded  me  of  the  so-called  old- 
fashioned  ovarian  tumors  of  the  Spencer  Wells  era.  It 
appeared  to  fill  the  whole  abdominal  cavity;  it  was  non- 
adherent,   and   sprang   from    the   right   ovarian   region;   its 


THE    PELVIS.  301 

lower  border  lay  deep  in  the  pelvis,  its  upper  border  rested 
against  the  liver  and  diaphragm;  it  was  multilocular  and 
in  the  midst  contained  a  dense  compartment,  so  thick  walled 
that  it  had  given  to  the  examining  hand  the  impression 
of  a  solid  tumor.  This  whole  mass  was  easily  delivered,  after 
the  abdomen  was  widely  opened.  I  did  not  tap  it,  as  I  be- 
lieve that  old-fashioned  method  is  often  hazardous  and  may 
give  rise  later  to  a  peritoneal  neoplasm,  should  the  tumor 
prove  to  be  malignant.  I  delivered  the  tumor  whole  and 
tied  off  its  pedicle  without  trouble.  The  cyst  and  its  contents 
weighed  sixteen  pounds.  There  were  about  ten  separate 
loculi,  but  no  signs  of  malignancy. 

The  patient  made  a  surprisingly  rapid  and  satisfactory 
recovery.  There  was  none  of  the  reaction  sometimes  seen 
after  the  removal  of  an  enormous  abdominal  tumor.  She 
left  the  hospital  at  the  end  of  two  weeks  and  shortly  returned 
in  health  to  her  regular  work,  which  she  has  followed  ever 
since. 


302  SURGICAL    PROBLEMS. 

Case  92.  On  November  2,  1908,  and  at  the  age  of  thirty- 
six,  Mrs.  Thornton  Ballinger  who  had  been  an  occasional 
patient  of  mine  for  some  ten  years,  sent  her  husband  to  con- 
sult me  regarding  the  wisdom  of  cutting  short  her  fifth 
pregnancy.  She  was  becoming  exhausted  with  a  pernicious 
vomiting,  the  pregnancy  being  some  two  months  advanced, 
and  eclampsia  threatening.  I  advised  a  consultation  with 
an  obstetrician,  but,  unfortunately,  was  that  day  myself 
called  out  of  town  on  an  urgent  errand,  which  detained  me 
for  five  days.  On  my  return  I  learned  that  Mrs.  Ballinger 
had  been  seen  by  my  consultant,  who  immediately  induced 
abortion  and  looked  to  a  speedy  improvement.  I  was  in- 
formed also  that  the  family  physician  was  now  in  charge  of 
the  case.  Assuming  that  all  was  going  well,  I  thought  no  more 
of  the  matter  for  a  week,  when  the  patient's  husband  tele- 
phoned to  me  that  she  was  suffering  from  a  mild  attack 
of  appendicitis.  I  saw  her  that  same  day,  and  concluded 
that  the  diagnosis  was  correct,  but  that  the  appendicitis 
was  subsiding.  The  next  day  the  pain  in  the  region  of  the 
appendix  had  disappeared,  but  there  supervened  apparently 
a  low  grade  of  pelvic  inflammation,  evidently  involving  the 
uterus  and  the  left  tube.  From  the  uterus  there  issued 
an  abundant  discharge  of  pus,  while  the  left  tube  was  easily 
palpable  and  tender.  The  patient's  general  condition  was 
extremely  feeble,  and  I  did  not  feel  justified  in  advising  an 
operation.^ 

^  The  cause  for  the  situation  I  have  described  is  not  im- 
mediately apparent.  A  patient,  the  victim  of  eclampsia, 
whose  uterus  is  cleared  out  by  a  competent  obstetrician, 
should  not  immediately  fall  victim  to  a  prostrating  sal- 
pingitis and  metritis,  yet  such  was  the  fate  of  this  patient. 
I  immediately  instituted  a  searching  inquiry  regarding  her 
previous  condition.  It  then  appeared  that  soon  after  mar- 
riage she  had  a  miscarriage  and  an  illness  which  suggested 
salpingitis.  She  had  attacks,  between  pregnancies,  of  pro- 
fuse leucorrhea  for  many  years,  and  for  more  than  a  year 
immediately  before  the  present  pregnancy  she  had  suffered 
from  a  constant  and  abundant  discharge  of  pus  from  the 
uterus. 


THE    PELVIS.  303 

I  was  forced  to  the  conclusion  that  the  present  pregnancy 
complicated  a  chronic  salpingitis,  and  that  with  the  develop- 
ment of  the  pregnancy  the  salpingitis  had  become  more 
acute,  lighting  up  fiercely  after  the  performance  of  abortion. 
The  question  of  treatment  now  became  urgent  and  difficult. 
In  order  to  gain  time,  and  in  the  hope  of  mitigating  the  symp- 
toms, I  instituted  a  vigorous  course  of  vaccine  treatment, 
which  for  four  or  five  days  brought  improvement,  with  a 
fall  of  temperature,  and  hope  of  permanent  gain.  On  the 
fifth  day,  however,  the  temperature  began  to  rise;  the  pain 
over  the  whole  pelvis,  and  especially  on  the  right,  increased 
greatly.  A  large  indefinite  mass  could  be  made  out  in  the 
neighborhood  of  the  right  tube.  On  the  morning  of  Novem- 
ber 19  the  temperature  was  102°,  the  pulse  no.  Two  hours 
later  the  temperature  had  risen  to  103°,  and  an  immediate 
operation  seemed  imperative,  if  the  patient  were  to  be 
saved.  Accordingly,  I  opened  the  abdomen,  in  the  patient's 
bedroom,  under  extremely  difficult  circumstances.  I  found 
the  uterus  and  pelvic  viscera  extensively  matted,  the  uterus 
retroverted  and  buried  in  adhesions.  Behind  it  was  an 
abscess  containing  six  ounces  of  greenish  pus,  apparently 
communicating  with  the  right  tube,  which  was  closely  tied 
down  behind  the  uterus.  The  left  tube,  on  the  other  hand, 
was  free,  and  the  left  ovary  normal  in  appearance.  The 
appendix  was  long,  injected  and  adherent  to  the  mass  of 
adhesions  on  the  right.  I  carried  out  the  obvious  maneuver 
of  removing  the  appendix,  the  right  tube  and  ovary,  and 
draining  the  abscess.  On  breaking  up  the  adhesions,  the 
uterus  swung  free,  and  I  was  able  to  suspend  it  firmly  from 
the  anterior  peritoneum.  There  was  moderate  hemorrhage. 
I  closed  the  abdomen,  draining  by  four  wicks.  Before  the 
operation  the  patient's  condition  had  appeared  desperate; 
she  survived  the  day,  however,  and  in  the  evening  seemed 
to  be  doing  fairly  well. 

The  interest  in  this  case,  and  the  problem  involved  up  to 
this  point,  lie  in  the  questions  of  etiology,  of  diagnosis  and 
of  treatment.  I  have  said  little  of  the  patient's  general 
health.  She  was  a  vigorous,  robust,  hardy,  out-of-doors 
woman,   and  to  that  fact  undoubtedly  she  owed  in  large 


304  SURGICAL   PROBLEMS. 

measure  her  ability  to  survive  so  serious  an  illness;  but 
her  troubles  were  not  yet  over.  The  operation  was  done 
on  the  19th  of  November.  For  some  four  weeks  she  made 
excellent  but  slow  progress  until  about  the  20th  of  De- 
cember, when  she  seemed  nearly  ready  to  leave  her  bed. 
Suddenly,  on  the  21st  of  December,  she  was  seized  by  an 
overwhelming  return  of  abdominal  pain,  with  rising  tempera- 
ture. The  pain  was  especially  severe  on  the  right  of  the 
uterus,  but  the  whole  abdomen  was  extremely  tender.  On 
making  a  pelvic  examination  I  could  find  little  to  explain 
the  situation,  save  that  the  uterus  was  heavy  and  tender, 
while  the  cervix  admitted  a  probe  with  difficulty.  Nothing 
peculiar  was  to  be  felt  outside  of  the  uterus  itself.  We 
remember  that  the  uterus  had  been  suspended  at  the  opera- 
tion a  month  previously.  My  belief  was,  therefore,  that 
the  trouble,  whatever  it  was,  lay  within  the  uterus,  that 
that  organ  had  become  acutely  infected  again,  and  that  it 
was  not  being  relieved  by  proper  drainage.  Accordingly, 
I  gave  Mrs.  Ballinger  gas  anesthesia,  dilated  widely  the 
cervix,  curetted  the  uterus,  allowing  the  escape  of  about 
two  ounces  of  pus,  and  inserted  a  tube-drainage  wick.  The 
patient's  condition  immediately  improved;  within  two  days 
all  sign  of  uterine  infection  had  subsided,  and  a  week  later 
she  began  getting  up  and  moving  about  her  room. 

All  experienced  surgeons  will  agree  that  so  severe  and  des- 
perate an  infection  as  I  have  described  is  often  followed  by 
long-continued  or  permanent  invalidism.  I  looked  for  some 
such  result  in  the  case  of  Mrs.  Ballinger,  but  I  was  most 
agreeably  disappointed.  Within  a  year  she  had  gained  thirty 
pounds,  and  had  gone  to  live  on  a  farm  in  the  country. 
To-day,  nearly  three  years  after  the  operation,  she  is  leading 
a  most  active  life,  constantly  out  of  doors,  employed  about 
the  gardens  and  the  fields,  active  in  the  rearing  of  her  three 
children,  and  in  better  health  than  she  has  known  since 
girlhood. 


THE  BOWEL. 

Case  93.  "  Rum  and  rheumatism  "  is  the  legend  I  find 
in  my  journal  under  the  name  of  Ishmael  Jex,  Boston, 
December  27,  1898.  This  man  was  forty-eight  years  old  at 
the  time  of  my  interview  with  him.  He  was  a  fair-weather 
lawyer,  employed  in  looking  after  his  estate  and  superintend- 
ing the  cuisine  of  a  comfortable  club.  In  early  life  he  had 
been  an  athlete,  immersed  in  the  affairs  of  the  militia,  and 
in  later  years  he  had  retired  from  such  activities  and  found 
solace  in  the  pleasures  of  the  table,  being  addicted  espe- 
cially to  champagne  and  other  forms  of  alcohol.  For  many 
years  he  had  suffered  from  what  he  called  rheumatism, — 
frequent  and  long-continued  pain  low  in  the  back,  stiff 
and  painful  knees,  and  especially  "  stiff  neck."  ^ 

On  examination,  Mr.  Jex  appeared  as  a  tall,  slight,  melan- 
choly man,  with  a  left-sided  limp,  long  of  body,  thin  chested, 
stooping  somewhat,  and  with  a  marked  protrusion  of  the 
lower  abdominal  region.  At  the  time  I  saw  nothing  in  his 
case  which  suggested  surgery,  as  we  then  looked  at  surgery, 
and  contented  myself  with  giving  him  careful  directions 
regarding  his  diet  and  abstinence  from  alcohol. 

Two  months  later,  on  the  27th  of  February,  1899,  he  sum- 
moned me  hastily  in  the  middle  of  the  night.  He  told  me, 
with  a  groan,  that  my  directions  had  resulted  in  making 
him  much  worse;  that  all  his  joint  pains  had  increased, 
and  that  he  was  troubled  with  continual  bellyache.  He  said 
that  that  night  especially  he  was  in  torture  with  low  ab- 
dominal pain,  acute  and  wearing;  he  was  nauseated  and  his 
bowels  had  not  moved  for  three  days.  On  examining  his 
abdomen,  I  found  it  slightly  distended,  with  a  point  of 
marked  tenderness  in  the  usual  region  of  the  cecum  and 
rigidity  of  the  right  rectus  muscle.  In  other  words,  he  was 
suffering  from  a  mild  attack  of  acute  appendicitis.  I  sug- 
gested, and  even  urged,  the  importance  of  a  prompt  operation, 
but  he  refused  flatly,  and  was  unwilling  even  to  see  another 

305 


306  SURGICAL   PROBLEMS. 

surgeon.  Accordingly,  I  did  my  best  to  steer  him  through 
the  attack,  and  had  the  satisfaction,  two  days  later,  of  find- 
ing him  free  from  abdominal  symptoms.  A  few  days  after- 
ward, and  while  still  convalescent,  the  patient  suffered  from 
a  severe  attack  of  acute  hemorrhoids.  Again  he  refused 
an  operation,  and  contented  himself  with  the  tedious  process 
of  treatment  by  cold  douches  and  appropriate  ointments. 
These  accumulated  disturbances,  acting  on  an  enervated 
organism,  made  an  invalid  of  the  man  for  a  time.  The  hemor- 
rhoids subsided  slowly,  while  their  subsidence  was  associated 
with  a  troublesome  proctitis.  The  rectal  mucosa  was  evi- 
dently extensively  inflamed,  and  discharges  of  muco-pus 
were  frequent.  For  some  days  he  refused  to  allow  me  to 
examine  the  rectum.  At  length,  however,  his  distress  became 
so  great  that  he  consented.  This  distress  seemed  to  me 
more  than  was  easily  accounted  for.  He  suffered  from  a 
continual  tenesmus,  and  assured  me  that  he  was  never 
free  from  cutting  pains,  running  up  into  the  abdomen  and 
down  the  left  leg.  At  the  same  time  his  temperature  began 
to  rise,  so  that  one  week  from  the  onset  of  the  hemorrhoids 
the  thermometer  registered  102°,  and  his  heart  was  beating 
at  the  rate  of  iio.^ 

On  the  7th  of  March  I  made  a  careful  digital  examination 
of  the  rectum.  A  proper  examination  by  inspection  was  im- 
possible without  the  use  of  an  anesthetic.  On  introducing 
my  finger  high  into  the  rectum,  which  I  did  against  the  man's 
screaming  and  saltating  protests,  I  encountered  a  soft, 
easily  bleeding,  velvety  mucosa,  while  at  the  finger  tip,  as 
high  as  I  could  reach,  there  was  an  indurated,  rough  mass, 
occupying  the  posterior  rectal  region  and  obstructing  the 
lumen  of  the  bowel.  It  was  not  especially  tender.  My 
patient  immediately  turned  to  me  at  the  end  of  the  exami- 
nation and  demanded  fiercely  the  nature  of  his  ailment. 
I  told  him  that,  so  far  as  I  could  judge,  he  was  suffering  from 
an  acute  infection,  but  that  I  was  unable  positively  to  rule 
out  a  tumor.  This  information  prostrated  him  with  grief 
and  anxiety.  The  next  day  Dr.  M.  H.  Richardson  saw  the 
man  with  me,  and  we  examined  him  carefully  under  ether 
anesthesia.      We    found    the    condition    much    as    I    have 


THE    BOWEL.  3O7 

described  it.  A  mass  upon  the  posterior  aspect  of  the  rectum 
impinged  upon  that  organ,  apparently  involving  the  mucosa; 
fixed,  in  extent  the  width  of  two  fingers,  and  admitting  a 
proctoscope  with  difficulty  beyond  it.  The  mucosa  over  the 
swelling  was  eroded  and  sloughy  in  appearance.  To  both 
of  us  it  seemed  highly  probable  that  the  mass  was  malignant 
but  we  were  not  altogether  satisfied  with  that  conclusion. 
For  the  next  three  or  four  days  the  patient  failed  perceptibly; 
his  appetite  vanished;  he  became  extremely  cachectic  in 
appearance;  his  pulse  ran  up  and  down  in  an  uncertain 
fashion,  and  he  carried  a  temperature  between  99°  and  102°. 
On  the  1 2th  of  March  we  decided  on  a  more  extensive  in- 
vestigation, and  called  as  an  additional  consultant  Dr.  J.  C. 
Warren.  After  the  patient  was  etherized,  my  consultants 
asked  me  first  to  dilate  the  sphincter  and  thoroughly  to  explore 
the  rectum,  while  they  looked  on  with  great  interest.  On 
dilating  the  sphincter  and  introducing  my  finger  cautiously 
into  the  bowel,  I  encountered  almost  at  once  the  tumor, 
which  seemed  to  have  increased  considerably  in  size  and  to 
be  softer.  As  I  endeavored  to  push  past  it,  it  suddenly  rup- 
tured, allowing  the  discharge  of  nearly  half  a  pint  of  mal- 
odorous pus.  The  diagnosis,  accordingly,  was  settled;  we 
were  dealing  with  a  simple  case  of  periproctitis,  with  abscess. 
The  patient's  temperature  dropped  at  once,  and  within  a 
few  days  he  regarded  himself  as  practically  well. 

None  the  less,  the  cause  of  this  surprising  and  acute 
attack  puzzled  me  for  some  time,  until  one  day,  in  discussing 
his  toilet  habits  with  the  victim,  I  learned  that  it  was  his 
custom  while  suffering  from  hemorrhoids  to  douche  out 
his  rectum  daily  with  cold  water.  For  this  purpose  he  used 
a  small-sized  Bidet  douche.  It  appears  that  one  day  while 
so  employed,  and  on  introducing  the  nozzle,  he  experienced 
sharp,  excruciating  pain  as  he  sat  upon  the  douche-bag. 
Undeterred  by  this,  however,  he  continued  his  douche,  and 
injected  a  considerable  amount  of  water.  To  his  surprise, 
a  small  part  only  of  the  water  returned.  From  that  event 
he  dated  his  severe  symptoms.  It  is  evident  that  in  some  way 
he  must  have  pushed  the  point  of  the  nozzle  beneath  the 
mucosa,   and  so  introduced   the  water  into  the  periproctal 


308  SURGICAL    PROBLEMS. 

tissue.  I  have  known  this  accident  to  happen  on  one  other 
occasion,  when  the  syringe  was  in  the  hands,  not  of  the  patient, 
but  of  an  experienced  nurse.  It  is  a  calamity  which  the  sur- 
geon should  bear  in  mind  when  investigating  mysterious  and 
acute  attacks  of  proctitis.^ 

^  As  I  look  back  now  at  this  case,  it  is  evident  that  his 
excesses  in  diet,  and  the  resulting  chronic  intestinal  dis- 
turbance, resulted  in  sacro-iliac  disease  and  other  forms  of 
arthritis. 

^  The  problem  in  this  case  is  twofold,  —  the  cause  and  treat- 
ment of  the  general  poor  condition  and  the  explanation  and 
treatment  of  the  severe  proctitis,  as  I  supposed  it  to  be  at 
that  time. 

^  About  a  year  ago  I  was  called  in  the  middle  of  the  night 
to  see  a  gentleman  who  was  suffering  from  agonizing  pain  in 
the  rectum.  I  found  him  sitting  and  straining  at  stool, 
passing  small  amounts  of  blood  and  groaning  in  agony. 
He  was  inarticulate  and  I  could  obtain  no  story  from  him. 
I  was  obliged  to  quiet  him  with  morphia  and  to  wait  until 
the  next  morning  before  further  questioning.  The  next  day, 
on  being  cross-examined,  his  wife  remembered  that  her  hus- 
band was  in  the  habit  of  employing  nightly  a  cool  water 
injection  to  cleanse  the  bowel,  that  there  hung  in  the  bath- 
room two  fountain  syringes,  one  of  which  was  used  occasion- 
ally for  corrosive  sublimate  vaginal  douches.  It  was  supposed 
to  be  kept  empty  always.  Through  some  carelessness,  it 
appears  that  my  patient  had  taken  the  syringe  containing 
the  dregs  of  the  corrosive,  had  added  water  to  it  and  had 
injected  the  combined  fluids  into  his  rectum.  There  followed 
the  agonizing  pain  which  I  have  described,  with  acute  tenes- 
mus and  the  passage  of  blood.  Some  days  elapsed  before 
this  patient  was  able  to  leave  his  bed.  The  mortification  of 
his  wife  was  extreme. 

Mr.  Jex  has  gone  his  way,  in  varying  health,  for  the  past 
twelve  years.  He  still  feebly  parades  the  streets,  and  reports 
with  pride  the  sound  condition  of  his  rectum. 


THE    BOWEL.  3O9 

Case  94.  Charles  Hodge,  a  young  clerk  in  the  town  of 
Yale,  was  sent  to  me  on  the  27th  of  August,  1907,  by  his 
family  physician.  He  was  nineteen  years  old  and  had  had 
a  somewhat  stormy  history.  Up  to  one  year  before  I  saw  him 
he  was  very  well  indeed, —  a  vigorous,  athletic  boy.  In  the 
summer  of  1906,  however,  he  complained  a  good  deal  of  pain 
in  the  right  loin,  and  consulted  Dr.  J.  C.  Munro,  who  ex- 
amined him  carefully  and  had  a  skiagraph  made  of  the  affected 
region,  but  discovered  no  positive  lesion.  Four  months 
before  I  saw  the  patient,  his  pain  had  increased,  when  he 
consulted  a  local  surgeon,  who  removed  his  appendix,  with- 
out any  special  benefit.  During  the  twelve  months  previous 
to  his  call  on  me  young  Hodge  had  been  so  frequently  ill 
that  he  was  obliged  to  give  up  work.  He  had  now  numer- 
ous attacks  of  pain  in  the  lower  left  abdominal  quadrant. 
This  pain  was  commonly  relieved  by  pressure.  When  It 
was  most  severe  it  caused  him  to  double  up,  with  groans. 
Apparently  it  was  in  no  way  related  to  the  action  of  the 
bowels  or  to  the  urinary  tract.  At  no  time  had  any  fever 
been  observed  in  connection  with  these  attacks.  I  was  told 
that  Dr.  Munro  thought  Hodge  to  be  the  victim  of  ureteral 
calculus,  although  no  calculus  or  gravel  had  been  found. 
The  patient  consulted  me  for  an  opinion  regarding  his 
recurring  and  distressing  left-sided  abdominal  pain. 

I  found  him  to  be  a  rather  slightly  built,  but  tall,  healthy- 
looking  young  fellow,  with  all  of  his  organs  sound  until  I 
came  to  the  lower  abdominal  region.  His  abdomen  was 
easily  palpable.  Abreast  of  the  crest  of  his  left  ilium  and 
in  the  line  of  the  ureter,  in  the  false  pelvis,  I  could  feel  a 
mass,  deeply  situated,  tender,  of  uncertain  consistency, 
not  movable,  apparently  about  the  size  of  an  English  walnut. 
It  seemed  undoubtedly  to  be  a  calculus,  or  an  inflammatory 
mass  resulting  from  a  calculus.  An  examination  of  the  urine 
at  that  time  showed  no  blood.  I  had  no  x-ray  taken,  perhaps 
unfortunately,  but  the  diagnosis  at  that  time  seemed  so 
assured   that  no   further  investigation   appeared   necessary. 

A  week  later  I  visited  the  young  man  in  his  home  town  and 
operated  upon  him,  opening  down  upon  the  left  ureter  through 
a  retroperitoneal  incision.     I  found  the  ureter  easily,  in  its 


310  SURGICAL    PROBLEMS. 

normal  position,  but  could  discover  no  stone  whatever, 
nor  was  there  anything  abnormal  in  the  appearance  of  the 
ureter,  —  no  thickening,  no  adhesions.  I  then  opened  the 
peritoneal  cavity,  in  the  sigmoid  region,  and  found  that 
the  sigmoid  was  extensively  adherent  to  itself  and  to  the  side 
of  the  pelvis.  The  presumable  reason  for  the  adhesions 
was  a  diverticulitis,  but  on  carefully  investigating  I  could 
discover  no  diverticulum  of  the  intestine.  We  drained  the 
peritoneal  cavity  and  closed  the  wound.  The  patient  re- 
covered promptly  and  soon  returned  to  his  old  work;  but 
that  was  not  the  end  of  him. 

On  the  2 1st  of  July,  1908,  nearly  a  year  after  my  first  in- 
terview with  Hodge,  he  called  upon  me  again,  by  the  request 
of  his  physician.  He  reported  that  for  three  months  after 
my  operation  he  felt  perfectly  well;  then  he  began  to  have 
frequent,  indefinite,  abdominal  pains,  associated  with  vom- 
iting after  food.  Sometimes  the  pain  was  definitely  located 
in  the  region  of  the  left  kidney,  and  would  shoot  down  along 
the  course  of  the  ureter.  For  eight  months  this  condition 
continued,  and  the  symptoms  had  increased  in  severity. 
The  boy  had  lost  five  pounds.  He  told  me  that  he  had  gone 
to  work  as  a  jeweler,  which  required  constant  sitting,  and 
that  he  felt  much  worse  when  at  work.  He  said  further 
that  earlier  in  the  summer  he  had  been  much  improved 
by  out-of-doors  sleeping.^  The  only  other  symptom  of  any 
consequence  was  an  obstinate  constipation,  which  was  re- 
lieved by  cathartics,  but  always  with  a  good  deal  of  general 
colicky  pain. 

^  A  good  deal  in  the  case  of  young  Hodge  suggests  what  we 
call  associated  pains,  or  neuroses,  but  we  have  back  of  us 
the  definite  fact  that  he  had  suffered  at  some  time  from  an 
inflammation  in  the  pelvis  which  had  left  his  sigmoid  adherent 
and  matted. 

On  examining  the  patient  again,  I  found  him  to  be  some- 
what larger  of  frame  than  the  year  before,  though  emaciated 
and  hectic.  His  temperature  was  99°,  pulse  94.  There  was 
an  extremely  tender  point  in  the  left  costo-vertebral  angle, 
and  he  was  tender  again  along  the  course  of  the  ureter; 


THE    BOWEL.  3II 

the  left  seminal  vesicle  was  easily  palpable  and  very  tender. 
He  now  told  me  that  he  was  troubled  with  frequent  mic- 
turition. Indeed,  the  whole  situation  suggested  strongly 
a  left-sided  genito-urinary  tuberculosis.  I  therefore  advised 
him  to  enter  a  hospital  for  tuberculin  tests  and  a  proper 
cystoscopic  examination.  He  did  so.  Tuberculin  tests  were 
negative.  A  careful  cystoscopic  examination  by  Dr.  Lincoln 
Davis,  however,  was  interesting.  In  brief,  he  stated  that 
the  urine  passed  was  high  colored  and  alkaline,  with  a  specific 
gravity  of  1027,  turbid,  with  a  heavy  sediment;  it  cleared 
up  on  the  addition  of  acetic  acid,  showing  the  presence 
of  an  active  phosphaturia;  there  was  no  albumen.  The 
bladder  was  practically  normal,  as  were  the  ureteral  orifices, 
except  that  there  was  some  slight  evidence  of  irritation 
in  the  trigonum,  due,  doubtless,  to  the  phosphaturia.  Both 
kidneys  were  shown  to  be  functionating  actively.  Dr. 
Davis  stated  that  there  was  no  evidence  whatever  of  renal 
or  ureteral  stone. 

With  rest  in  bed  for  a  week,  and  the  use  of  diuretics  and 
urotropin,  the  young  man's  symptoms  decreased  greatly. 
Indeed,  he  regarded  himself  as  well,  and  was  allowed  to  go 
home.  He  went  home,  lived  on  a  somewhat  limited  diet, 
with  little  nitrogen,  and  took  considerable  amounts  daily 
of  benzoate  of  soda.  I  saw  nothing  of  him  for  two  months 
longer,  when  he  consulted  me  at  the  end  of  September, 
complaining  bitterly  that  his  pain  was  worse  than  ever, 
that  he  was  becoming  a  debilitated  invalid,  and  demanding 
that  something  be  done. 

Here  we  were,  then,  at  the  end  of  a  year  of  treatment,  with 
the  patient  still  on  our  hands,  as  badly  off  as  ever  and  no 
positive  diagnosis  in  sight.  I  was  unable  to  make  any  diag- 
nosis of  surgical  disease.  The  patient  gladly  consented,  how- 
ever, to  consult  an  internist,  who  made  a  further  and  most 
thorough  examination.  While  reaching  no  vital  point  which 
had  not  already  been  covered  apparently,  this  physician 
noted  the  fact  that  the  patient  flushed  furiously  with  his 
attacks  of  pain,  and  that  there  was  to  be  found  high  in  the 
rectum,  behind  one  of  Houston's  valves,  an  extremely  ten- 
der point,  as  though  of  a  slight  ulceration.     This  consultant 


312  SURGICAL   PROBLEMS. 

pointed  out  these  facts  to  me,  and  suggested  that  the  whole 
difficulty  might  be  regarded  as  circulatory.  He  continued 
the  use  of  alkaline  drinks,  treated  locally  the  ulcer  of  the 
rectum,  by  gentle  applications  of  nitrate  of  silver,  and  put 
the  young  man  on  a  course  of  strychnia,  as  a  general  cir- 
culatory stimulant.  The  patient's  improvement  was  instant 
and  remarkable.  Within  a  week  he  had  thrown  off  his  de- 
spondency; he  found  himself  relatively  free  from  pain,  with 
improved  appetite  and  bowels,  and  little  rectal  distress. 
A  month  later  he  returned  to  his  work,  and  soon  forgot 
his  pains  and  the  directions  of  his  latest  physician.  How- 
ever, he  continued  well  for  nearly  two  years,  when  he  con- 
sulted me  again,  this  time  in  July,  1910.  I  found  his  condi- 
tion much  as  I  had  seen  it  in  1907.  He  was  emaciated, 
querulous,  complaining  constantly  of  pain,  stating  that  he 
was  unable  to  work,  pointing  to  his  left  renal  and  ureteral 
region,  and  praying  for  relief.  Again  I  put  him  at  once  on 
the  treatment  which  had  helped  him  so  much  before, —  di- 
uretics, laxatives  and  strychnia.  Again  he  improved  promptly. 
I  have  not  seen  him  since,  but  I  am  told  that  his  health  con- 
tinues fair,  and  that  so  long  as  he  follows  a  proper  regimen 
of  tonics  and  out-of-doors  sleeping  he  suffers  from  no  more 
of  his  old-time  attacks. 

This  is  an  instructive  case  —  a  borderland  case,  not  sur- 
gical. There  is  no  climax.  The  story  wanders  on  and  may 
wander  on  for  years  to  come,  but  the  significance  of  a  search- 
ing examination  and  the  application  of  first  principles  is 
apparent. 


THE    BOWEL.  3I3 

Case  95.  The  following  case  presents  a  problem  of  some 
ethical  interest,  though  the  pathology  involved  is  simple 
and  rather  unimportant. 

On  the  2 1  St  of  October,  1909,  Mrs.  Rebecca  Snow,  twenty- 
four  years  of  age,  consulted  me  on  the  advice  of  her  physician. 
She  was  five  months  married  and  stated  that  she  had  been 
far  from  well  for  more  than  eight  years.  While  always 
a  robust,  ruddy  and  vigorous-looking  girl,  she  said  that  she 
had  suffered  from  recurring  anal  fistulae  and  discharges  of 
pus  from  the  rectum  since  she  was  sixteen  years  old.  I 
was  obliged  to  assume  that  her  habits  had  been  good  and 
that  she  had  never  suffered  from  venereal  disease.  She 
said  that  she  had  been  operated  upon  three  or  four  times 
for  fistula,  but  without  permanent  benefit. 

When  she  consulted  me  Mrs.  Snow  was  a  plump,  well- 
developed  looking  young  woman,  who  seemed  to  have  her- 
self perfectly  in  hand.  On  careful  rectal  and  vaginal  examina- 
tion I  detected,  deep  in  the  recto-vaginal  septum,  a  broad, 
firm,  cicatricial  thickening,  pressure  on  which  caused  the 
escape  of  pus  from  a  minute  opening  in  the  right  buttock 
one  inch  behind  the  anus,  while  on  my  slightly  distending 
the  sphincter,  pus  oozed  from  the  anus  also. 

I  sent  the  patient  to  a  hospital,  and  operated  on  her 
there  the  next  day,  with  the  advantage  of  having  present 
her  family  physician,  who  had  known  her  since  her  child- 
hood. On  dilating  the  sphincter  and  examining  carefully 
the  rectum,  I  developed  again  the  deep  induration  in  the 
recto-vaginal  septum,  which  was  the  base,  apparently, 
of  an  abscess.  Several  ounces  of  muco-pus  escaped  from  the 
rectum.  On  passing  a  probe  through  the  lower  sinus  in  the 
buttock  it  entered  the  rectum.  I  laid  open  the  sinus  and  care- 
fully dissected  it  out.  The  sphincter  was  not  markedly 
damaged  by  this  little  operation.  Careful  inspection  of  the 
rectum  showed  further  a  marked  and  extensive  proctitis, 
evidently  the  primary  source  of  the  pus.  The  sacrum  and 
coccyx  were  not  involved.  After  these  manipulations 
the  recto-vaginal  induration  disappeared.  I  packed  care- 
fully the  track  of  the  old  fistula, —  which,  by  the  way,  was 
the  only  fistula  present,  while  there  were  no  evidences  of 


314  SURGICAL   PROBLEMS. 

former  fistulae  or  other  operations, —  and  washed  out  the 
rectum,  giving  directions  for  daily  irrigations  of  the  bowel 
with  argyrol. 

This  patient  made  an  excellent  convalescence  and  went 
home  two  weeks  after  the  operation.  Some  five  days  before 
she  left  the  hospital,  her  husband,  an  active  young  mechanic, 
but  a  rather  loose  fish  about  town,  consulted  me  about  him- 
self. He  came  to  the  point  at  once  and  admitted  that  since 
his  wife's  illness  he  had  been  unfaithful  to  her  and  had 
contracted  gonorrhea.  He  asked  my  advice  regarding  treat- 
ment. I  pointed  out  to  him  the  difficulty,  if  not  the  impro- 
priety, of  my  caring  for  him,  and  referred  him  to  another 
surgeon  for  treatment.  Thereafter  the  wife  came  frequently 
to  my  office  for  consultation  and  treatment.  The  fistula 
wound  closed  well  and  the  sphincteric  action  was  restored 
completely,  but  her  proctitis  persisted  for  a  long  time. 
For  a  year  or  more,  at  proper  intervals,  I  saw  her  and  gave 
her  directions  regarding  weak  silver  irrigations,  which  she 
was  able  to  take  in  large  amounts  and  eventually  of  con- 
siderable strength.  At  length  the  inflammation  subsided 
and  she  became  practically  well. 

In  the  course  of  this  experience,  and  perhaps  two  weeks 
after  my  interview  with  her  errant  husband,  she  came  to 
me  in  great  distress,  saying  that  she  had  developed  a  new 
difficulty  and  was  convinced  that  she  had  contracted  gon- 
orrhea from  her  husband.  A  careful  examination  revealed 
little  or  nothing  save  a  slight  catarrhal  discharge  from  the 
cervix.  A  number  of  investigations  failed  to  discover  the 
diplococcus  of  Neisser.  I  had  her  take  a  few  creolin  douches, 
and  in  the  course  of  a  couple  of  weeks  the  apparent  disturb- 
ance disappeared  entirely,  so  that  I  felt  justified  in  assuring 
her  that  she  had  no  evidence  whatever  of  gonorrheal  infec- 
tion. Some  six  weeks  after  the  husband's  mishap,  however, 
the  wife  came  to  me  again  and  asserted  her  conviction  that 
her  whole  illness  was  due  to  her  relations  with  her  diseased 
husband.  She  denied  flatly  her  previous  story  that  she  had 
had  fistulae  and  proctitis  for  eight  years  before  marriage, 
and  attempted  to  convince  me  that  her  rectal  disturbance 
was  due  to  marital  infection.     She  then  consulted  her  at- 


THE    BOWEL.  315 

torney,  an  unscrupulous  lawyer,  whose  main  purpose  seemed 
to  be  to  make  trouble  for  me  and  to  expose  the  misfortunes 
of  his  client.  The  question  put  to  me  and  the  proposition 
which  I  was  threatened  with  as  a  witness  on  the  witness- 
stand  was,  —  Had  Mr.  Snow  consulted  me  regarding  his 
own  health;  did  I  find  him  to  be  suffering  from  gonorrhea; 
and  was  it  reasonable  to  suppose  that  he  had  infected  his 
wife?  I  refused  positively  and  at  once  to  have  any  dealings 
with  Mrs.  Snow's  attorney.  I  notified  Mr.  Snow  of  the 
nature  of  his  wife's  inquiry,  and  informed  the  surgeon  to 
whom  I  sent  him  of  the  situation.  At  least  once  a  week  dur- 
ing several  months  thereafter  the  woman's  attorney  either 
came  to  see  me  or  called  me  on  the  telephone,  threatening 
exposure  of  the  wife,  assuring  me  that  my  professional 
knowledge  was  at  the  disposal  of  the  court,  asserting  that 
I  was  concealing  an  act  which  was  little  short  of  criminal,  and 
promising  without  fail  to  cross-examine  me  on  the  witness- 
stand.  Meantime  the  woman  had  brought  suit  against  her 
husband,  and  in  her  visits  to  my  office  continually  referred  to 
its  development.  I  was  informed  by  the  husband's  attorney, 
an  excellent  man  of  high  professional  standing,  that  his  client 
had  no  intention  of  contesting  the  suit,  that  he  admitted  his 
infidelity  and  was  quite  willing  to  let  the  law  take  its  course; 
moreover,  as  he  was  a  poor  man,  there  seemed  no  possibility  of 
his  being  able  to  pay  damages  for  the  havoc  he  had  wrought. 
As  I  look  back  upon  this  annoying  and  repulsive  experience, 
I  feel  satisfied  that  the  course  I  took  was  the  correct  and 
proper  one.  Had  the  man  continued  to  live  with  his  wife, 
it  might  have  been  my  duty  to  warn  her  against  him,  but 
under  the  circumstances,  as  a  physician,  I  believe  that  I 
did  all  that  was  necessary  to  save  the  pathological  situation. 
So  far  as  I  was  concerned,  the  case  eventually  came  to  nothing. 
The  woman's  attorney  was  finally  wearied  by  my  attitude, 
and  tacitly  admitted  that  he  would  be  unable  to  force  from 
me  a  statement  of  the  husband's  ailment.  Eventually,  the 
case  was  settled  by  divorce,  and  the  woman  was  happy 
enough  to  be  freed  from  her  incumbrance.  I  still  see  her 
occasionally.  The  proctitis  has  practically  subsided,  and  I 
regard  her  as  being  as  well  as  she  is  ever  likely  to  be. 


THE  SCROTUM. 

Case  96.  Young  Marcus  Crawford,  hailing  from  St. 
Louis  and  an  undergraduate  in  Cambridge,  called  to  see  me 
on  the  1 8th  of  October,  1909.  He  was  twenty  years  old. 
His  story  was  that  some  five  days  previously,  while  taking 
part  in  a  college  celebration  over  an  athletic  victory,  he  had 
been  roughly  pushed  across  a  board  fence,  which  he  was 
forced  to  straddle  violently,  with  the  result  that  his  peri- 
neum and  scrotum  were  badly  bruised.  He  thought  it  pos- 
sible that  he  might  have  been  struck  in  a  football  scrimmage 
in  the  same  anatomical  region  a  couple  of  weeks  previously, 
but  of  that  he  was  not  certain.  For  three  or  four  days  he 
had  noticed  a  swelling  of  the  right  testicle,  and  was  troubled 
about  the  nature  of  the  condition.  He  had  always  been 
a  healthy  lad  and  came  of  vigorous  stock  on  both  sides  of 
the  family,  in  which  there  was  no  tuberculous  taint.  He  had 
never  had  venereal  disease,  and  was  regarded  in  college  as 
typical  athletic  material. 

I  found  young  Crawford  to  be  a  tall,  ruddy,  well-developed 
lad,  without  any  obvious  sign  of  physical  disorder  until 
I  examined  the  scrotum.  The  testicle  itself  seemed  of  normal 
size,  but  the  epididymis  was  markedly  swollen  and  was  as 
large  as  a  half  of  one's  closed  fist.  There  was  no  pain  in  the 
region  and  little  or  no  tenderness.  Considering  the  story 
and  the  young  man's  previous  history,  it  seemed  that  he  was 
suffering  from  a  traumatic  epididymitis.^ 

^  Traumatic  epididymitis  and  traumatic  orchitis  are  less 
rare  than  is  commonly  supposed.  In  considering  tumors 
within  the  scrotum,  one  must  bear  in  mind,  however,  that 
the  variety  of  such  tumors  is  great,  inasmuch  as  the  contained 
structures  furnish  a  histology  which  may  give  rise  to  an 
unusual  variety  of  growths.  One  thinks  especially  of  sar- 
coma, of  tuberculosis,  of  dermoid  tumors,  hernia,  hydrocele, 
hematocele,  gonorrheal  epididymitis  and  orchitis,  and  that 
somewhat  rare  lesion,  twisted  cord,  with  strangulated 
testicle. 

317 


3l8  SURGICAL   PROBLEMS. 

I  sent  the  patient  to  a  hospital  and  put  him  to  bed,  for 
rest  and  observation.  Three  days  later  the  swelling  had 
decidedly  diminished,  and  the  improvement  continued  for 
ten  days,  when  I  allowed  him  to  go  back  to  his  quarters  at 
college.  I  saw  him  occasionally  during  the  next  month,  but 
after  the  first  two  weeks  the  condition  remained  practically 
unchanged.  On  the  226.  of  November  he  came  to  my  office, 
at  which  time  I  made  the  following  note  of  his  condition: 
"  The  right  epididymis  and  cord  are  still  large,  hard  and 
heavy.  The  cord  is  easily  traced  up  into  the  ring.  By 
rectum,  the  right  seminal  vesicle  is  felt,  for  the  first  time, 
and  the  prostate  seemed  slightly  enlarged  and  hard  on  the 
right.  The  patient  feels  absolutely  well,  and  wishes  to 
postpone  any  further  treatment  for  a  week.  I  advise  further 
hospital  care  and  tuberculin  tests."  By  this  time  I  had  begun 
to  feel  seriously  uneasy  about  the  lad's  condition,  and  wrote 
to  his  father,  in  St.  Louis,  that  his  progress  was  unsatisfac- 
tory and  that  I  suspected  the  presence  of  a  tuberculosis. 
The  father  was  naturally  much  troubled,  and  came  on  at 
once  to  Boston.  I  saw  him  with  the  boy,  on  November  29, 
one  week  after  the  date  of  the  previous  consultation.  On 
that  day  there  was  little  change  to  be  noted  in  the  physical 
examination  of  the  young  man.  The  epididymis  was  de- 
cidedly swollen  and  the  globus  major  hard;  the  cord  also 
was  distended  and  hard;  the  prostate  and  right  seminal  vesicle 
were  easily  palpable  and  a  cord-like  vas  could  be  detected. 

I  sent  the  patient  at  once  to  the  hospital  for  further  in- 
vestigation, and  started  a  series  of  tuberculin  tests.  On  that 
day  Dr.  F.  B.  Harrington  saw  the  patient  with  me,  and 
agreed  that  in  all  probability  the  case  was  one  of  genito- 
urinary tuberculosis.  The  father,  in  his  anxiety,  in  the  mean- 
time had  consulted  his  family  physician  in  St.  Louis,  a  man 
of  wide  acquaintance,  who  suggested  our  securing  the  opinion 
of  a  well-known  genito-urinary  specialist  in  Boston.  This 
last  consultant  saw  the  patient  with  me  two  days  later. 
He  was  positive  that  the  case  was  not  one  of  tuberculosis. 
He  is  a  man  of  the  widest  experience,  and  after  a  careful 
investigation  decided  that  many  of  the  characteristic  signs 
of  tuberculosis  were  wanting.     His  conviction  was  that  we 


THE    SCROTUM.  319 

had  to  deal  with  a  slight  chronic  twist  of  the  cord,  probably 
induced  by  the  rough  handling  at  the  board  fence  which  I 
have  described.  Three  days  later  another  tuberculin  in- 
jection was  followed  by  no  reaction,  and  this  result  seemed 
to  go  far  towards  justifying  the  diagnosis  of  a  traumatic 
disturbance,  rather  than  tuberculosis.  All  this  time  the 
general  condition  of  the  patient  remained  excellent,  but  the 
case  was  one  extremely  trying  to  all  the  consultants,  as  an 
assured  diagnosis  was  extremely  important  and  the  anxiety 
and  concern  of  the  boy's  parents  were  becoming  daily  more 
critical.  Perhaps,  fortunately  for  all  concerned,  the  third 
tuberculin  test  appeared  to  clear  up  the  diagnosis.  This 
was  made  on  the  3d  of  December,  six  days  after  the  first  test. 
This  third  test  gave  a  marked  tuberculin  reaction.  The  tem- 
perature rose  to  103°,  the  pulse  to  no,  and  Dr.  Floyd,  the 
expert  in  the  work,  reported:  "  I  regard  this  as  a  typical 
tuberculin  reaction,  moderately  severe,  as  shown  from  the 
temperature,  nausea  and  vomiting,  the  chill  and  the  patient's 
red  arm."  Somewhat  elated  over  this  presumably  final 
demonstration,  I  met  again  in  consultation  the  specialist 
to  whom  I  have  referred.  We  agreed  that  the  patient's 
epididymis  showed  no  local  disturbance  after  the  tuberculin, 
but  we  discovered  a  marked  tenderness  and  a  slight  tumor 
in  the  region  of  the  right  kidney.  My  consultant  continued 
to  regard  the  scrotal  lesion  as  possibly  due  to  twist  of  the  cord, 
but  admitted  that  there  might  be  present  a  renal  tuberculo- 
sis, and  agreed  with  me  that  an  exploration  of  the  contents 
of  the  scrotum  was  justifiable. 

At  this  point  the  parents  of  the  young  man  informed  us 
that  they  had  decided  to  remove  him  at  once  to  his  home  in 
St.  Louis,  where  a  local  surgeon  would  perform  the  indicated 
operation.  The  day  before  the  patient's  removal  from  the 
hospital  a  careful  urinalysis  was  made,  with  the  following 
result:  "  Urine:  normal  color,  cloudy,  acid,  a  large  trace 
of  albumen,  no  sugar,  uric  acid  increased.  Sediment:  some 
blood  corpuscles,  numerous  leukocytes,  sufficient  in  amount 
to  cloud  the  urine,  occasional  squamous  and  large  and  small 
round  cells,  no  casts.  The  urine  was  centrifuged  and  one 
portion    stained,    for    tubercle    bacilli;    they    were    absent. 


320  SURGICAL    PROBLEMS. 

A  second  portion  was  inoculated  into  a  guinea  pig."  The  date 
of  that  report  was  December  6.  On  the  ist  of  January, 
1910,  I  received  the  following  note  from  Dr.  Floyd:  "The 
guinea-pig  inoculated  on  December  6  with  the  centrifuged 
urinary  sediment  obtained  from  the  urine  of  Mr.  Crawford 
showed  at  autopsy  to-day  a  caseous  mass  in  the  abdominal 
wall.  Smears  from  the  wall  of  the  cavity  showed  numerous 
tubercle  bacilli  to  be  present." 

Meantime,  and  after  the  departure  of  the  patient  for 
St.  Louis,  I  received  numerous  letters  from  his  family  and 
his  physician.  The  upshot  of  it  all  was  that  after  due  con- 
sideration an  operation  on  the  scrotum  was  performed. 
The  testicle  and  cord  were  removed  and  found  to  be  mark- 
edly tuberculous.  Fortunately,  the  patient  reacted  vigor- 
ously and  recovered  shortly  from  the  ordeal.  Since  that  time 
his  condition  has  greatly  improved.  The  kidney  was  found 
to  be  tuberculous,  as  evidenced  by  the  condition  of  the 
urine  and  the  presence  of  tubercle  bacilli,  but  after  a  course 
of  six  months  out-of-doors  life  the  trouble  cleared  up,  and 
now  for  many  months  there  has  been  no  evidence  of  tuber- 
culosis in  the  young  man. 

There  is  a  good  deal  in  this  case  which  is  instructive  and 
interesting;  the  fact  that  the  patient  could  run  a  considerable 
course  of  marked  tuberculosis  without  constitutional  dis- 
turbance, feeling  all  the  time  strong  and  vigorous;  the  diffi- 
culty of  the  diagnosis,  which  was  established  finally  by 
guinea-pig  inoculation;  the  prompt  recovery  of  the  patient 
after  the  operation;  and  finally  the  marked  permanent  im- 
provement which  resulted  from  a  prolonged  out-of-doors 
life,  even  after  the  obvious  establishment  of  a  renal  tuber- 
culosis. This  patient  came  from  the  best  of  surroundings 
and  an  extremely  intelligent  family.  Doubtless  he  was  seen 
as  early  as  these  cases  are  ever  seen,  and  received  the  most 
vigorous  and  appropriate  treatment.  Our  conclusions  are 
therefore  encouraging  and  gratifying,  so  far  as  one  may  draw 
conclusions  from  a  single  case,  namely, —  that  a  pronounced 
genito-urinary  tuberculosis,  when  submitted  to  appropriate, 
energetic  and  prolonged  treatment,  may  subside,  and  the 
patient  return  to  a  normal  and  healthy  life. 


GENITO-URINARY. 

Case  97.  The  experience  of  the  Rev.  John  Aquinas 
illustrates  a  pathetic  and  tragic  case,  rather  than  a  puzzling 
surgical  problem,  but  the  story  is  so  unusual  and  the  psychic 
element  so  prominent  tliat  it  seems  worth  recording.  I 
give  the  sequence  of  events  as  they  were  presented  to  me. 

On  the  20th  of  March,  1899,  a  veiled  lady,  fragile  and 
timid,  came  into  my  office  late  in  the  afternoon.  She  did  not 
raise  her  veil,  nor  in  my  subsequent  interviews  with  her  did 
I  ever  see  her  face.  She  told  me  that  her  husband,  a  clergy- 
man, Mr.  Aquinas,  the  incumbent  of  a  large  parish  in  the 
north  of  England,  was  seriously  ill;  that  his  illness  was  of 
such  a  nature  as  to  preclude  his  consulting  his  family  physi- 
cian; that  the  disease  had  now  run  on  for  three  months; 
and  that,  in  desperation  and  distress,  he  had  resolved  to  come 
to  this  country  to  seek  advice.  She  stated  that  she  supposed 
the  ailment  was  a  disease  of  the  scrotum,  but  she  could  tell 
me  little  more.  At  the  time  of  her  visit  her  husband  was  in 
New  York,  awaiting  the  result  of  her  consultations  in  Boston. 
She  said  that  she  had  gone  to  the  Massachusetts  General 
Hospital,  and  from  there  was  referred  to  me,  as  I  was  then 
on  duty  there.  She  asked  me  if  I  would  undertake  the 
charge  of  the  case.  On  my  promising  to  do  what  I  could, 
she  said  that  the  patient  would  arrive  in  Boston  in  a  very 
few  days. 

Four  days  later  I  was  summoned  to  a  neighboring  hotel 
to  see  Mr.  Aquinas.  The  door  of  the  apartment  was  opened 
to  me  with  much  mystery,  and  I  was  ushered  into  a  bedroom 
where  the  patient  sat  in  his  bed,  and  almost  before  I  was 
in  the  room  began  an  excited  and  lachrymose  story.  He  said 
that  he  did  not  know  whether  I  would  be  willing  to  help 
him  or  not;  that,  as  a  clergyman,  the  conditions  of  his  ill- 
ness were  tragic  and  shocking,  and  the  circumstances  as 
follows:  Some  three  months  ago  he  went  to  London  to  attend 
a  church  convention,   leaving  his  wife  and   six  children  at 

321 


322  SURGICAL   PROBLEMS. 

home  in  the  Provinces.  While  in  London  he  was  taken  ill 
with  acute  rheumatism,  and  supposing  that  a  Turkish  bath 
and  massage  would  help  him,  he  had  inquired  the  way  to 
a  proper  Turkish  bath  establishment.  After  the  bath  he 
asked  for  massage,  whereupon  there  came  into  the  apart- 
ment where  he  lay  a  young  woman,  who  turned  out  to  be 
of  evil  character.  She  massaged  him  and  he  remained  with 
her  some  half  hour  afterward.  He  then  left  the  establish- 
ment with  a  feeling  of  horror  and  disgrace,  realizing  that  he 
had  offended  against  the  moral  code.  All  that  night  he  walked 
the  streets,  in  the  greatest  mental  distress  and  remorse. 
Five  days  later  he  discovered  that  he  was  the  victim  of  an 
acute  gonorrhea.  The  next  three  months  registered  a  record 
of  the  greatest  mental  anguish.  He  dared  not  consult  a  physi- 
cian, he  dared  not  employ  quack  remedies,  for  fear  his  iden- 
tity should  be  discovered;  in  fact  he  went  on  without  treat- 
ment. At  once,  on  his  return  home,  he  made  a  clean  breast 
of  the  affair  to  his  wife,  who  accepted  the  situation  and  did 
all  in  her  power  to  relieve  and  sustain  him.  Finally  the 
disease,  which  had  rim  on  with  great  virulence,  involved  his 
bladder  and  right  testicle.  Then,  in  desperation,  he  took 
ship  and  came  to  America,  with  the  purpose  of  seeking  proper 
advice  and  treatment  at  the  hands  of  some  person  unknown 
to  him  and  his  circumstances.  He  assured  me  that  up  to  the 
time  of  his  recent  misfortune  he  had  always  been  strong 
and  vigorous,  had  never  indulged  in  stimulants,  and,  although 
of  a  nervous  temperament,  had  been  effective  and  useful 
in  his  profession. 

On  examination,  I  found  the  patient  to  be  a  man  of  forty- 
five,  tall,  sandy,  strong  of  feature  and  highly  intelligent. 
He  was  well  developed,  but  greatly  emaciated.  He  was  in 
every  way  sound  save  for  the  disease  in  question.  On  ex- 
amining the  urethra  I  found  it  to  be  but  a  little  involved ;  the 
urethritis  had  practically  disappeared ;  there  was  no  stricture, 
and  an  examination  of  the  urine  showed  merely  a  very  slight 
degree  of  cystitis;  the  right  seminal  vesicle  was  full,  hard 
and  tender,  and  the  prostate  was  somewhat  enlarged  on  the 
right;  the  left  scrotum  was  not  abnormal,  but  on  the  right 
side  was  a  mass  about  the  size  of  a  man's  fist,  brawny,  tender, 


GENITO-URINARY.  323 

smooth,  and  at  one  point  fluctuant;  the  mass  was  so  exten- 
sive and  the  sweUing  so  uniform  that  the  epididymis  could 
not  be  properly  distinguished.  At  first  it  seemed  possible 
that  the  inflammatory  process  might  be  subdued  by  ordinary 
measures,  and  for  two  days  I  endeavored  to  allay  the  progress 
of  the  inflammation  by  rest  and  applications.  At  the  end 
of  that  time,  however,  it  was  evident  that  such  measures 
would  prove  ineffective.  Accordingly,  and  with  some  hesi- 
tation, I  broached  the  subject  of  orchidectomy  to  the  patient, 
feeling  that,  in  his  then  mental  condition,  the  thought  of  any 
venereal  crippling  might  prove  a  great  shock.  On  the  contrary 
he  accepted  the  situation  with  the  greatest  alacrity,  evidently 
feeling  that  the  loss  of  a  testicle  must  be  regarded  in  some 
sense  as  a  punishment  for  offense,  and  that  doubtless  prompt 
recovery  would  result.'^  The  only  stipulation  made  by  the 
patient  was  that  no  one  should  know  the  nature  of  his  ailment. 
At  first  it  seemed  almost  Impossible  to  meet  this  wish.  How- 
ever, I  got  around  the  problem  by  informing  the  hospital 
to  which  I  sent  him,  and  my  assistants,  that  the  case  was  one 
of  tumor  of  the  scrotum. 

Two  days  later  I  operated,  and  by  the  high  Incision,  a 
method  which  enables  the  surgeon  to  clean  out  the  scrotum 
easily  and  often  without  exposing  the  nature  of  the  tumor.  ^ 

^  The  necessity  for  orchidectomy  Is  extremely  rare  in 
cases  of  gonorrheal  epididymitis ;  indeed  such  necessity  should 
only  arise  in  cases  of  long-neglected  disease.  Such  was  the 
situation  in  the  patient  under  discussion.  The  infection 
of  the  epididymis  had  taken  place  six  weeks  before  I  saw  him, 
and  the  destruction  of  tissue  was  apparently  complete. 

^  For  many  years  I  have  employed  the  high  operation  for 
disease  within  the  scrotum.  The  technique  consists  in  opening 
down  upon  the  spermatic  cord,  as  though  one  were  operating 
for  inguinal  hernia.  The  incision  is  carried  down  to  the  base 
of  the  scrotum,  when  with  a  little  manipulation  it  is  an  easy 
matter  to  turn  out  the  contents  of  the  scrotum  into  the  ab- 
dominal wound,  after  which  the  necessary  treatment  may 
be  carried  out  at  ease,  with  all  the  parts  in  sight  and  in 
hand.  This  measure  is  applicable  especially  to  all  forms 
of  tumors  which  do  not  involve  the  skin,  and  to  hydroceles. 
A  further  advantage  of  the  method  is  that  the  wound  is 
placed  in  an  easily  accessible  and  convenient  position,  that 


324  SURGICAL   PROBLEMS. 

the  scrotum  itself  is  not  opened  except  from  above,  and  that 
the  subsequent  dressings  and  care  of  the  wound  are  facili- 
tated and  made  easy  for  the  patient  himself.  A  snug  sus- 
pensory bandage  should  always  be  worn  during  convalescence. 

I  found  no  difficulty  in  turning  out  the  infected  mass  and 
amputating  the  cord  high  in  the  canal.  Subsequently,  on 
examining  the  mass,  I  found  it  to  be  a  collection  of  broken- 
down  material,  swimming  in  pus.  The  wound  was  closed 
with  drainage,  and  the  patient  made  a  prompt  and  satis- 
factory recovery.  Seven  days  after  the  operation  sound 
primary  union  was  established. 

I  was  greatly  interested  in  this  patient.  He  was  a  man 
of  unusual  force  of  character  and  intellectual  capacity.  I 
have  heard  from  him  many  times  in  the  course  of  the  last 
ten  years.  After  returning  home  he  took  up  vigorously  his 
work  again,  and  has  often  assured  me  that  the  harsh  experi- 
ence, the  sense  in  himself  of  having  fallen  victim  to  temp- 
tation, and  his  realization  of  personal  human  error  had 
immensely  increased  his  capacity  for  usefulness.  I  learn  that 
he  is  still  at  work  in  the  successful  conduct  of  a  large  parish. 


ABDOMINAL  ADHESIONS. 

Case  98.  Bridget  Flanagan  entered  the  Massachusetts 
General  Hospital  on  the  15th  of  February,  191 1.  She  was 
said  to  be  the  victim  of  extensive  abdominal  adhesions. 
She  was  forty  years  old,  and  for  three  years  had  been  an 
invalid.  She  herself  and  the  records  of  the  hospital  told 
the  following  story:  Married  at  twenty-five  and  always 
a  hard-working  woman,  she  had  borne  three  children,  and 
had  enjoyed  excellent  health  up  to  the  age  of  thirty-seven. 
There  was  no  history  of  severe  sickness,  nor  was  there  the 
common  story  of  dyspepsia.  She  had  suffered  all  her  life, 
however,  from  an  obstinate  and  difficult  constipation.  Dur- 
ing the  year  1907  her  present  ill-health  began.  Four  times 
during  that  year  she  suffered  from  what  appeared  to  be  at- 
tacks of  moderate  appendicitis,  with  slight  fever,  pain  and 
tenderness  in  the  usual  region,  nausea  and  vomiting  and 
several  days  of  inflammatory  obstruction  to  the  bowels. 
Finally  the  condition  became  so  urgent  that  she  entered  the 
hospital  for  an  operation.  The  appendix  was  removed, 
and  the  records  state  that  it  was  the  seat  of  a  mild,  catarrhal 
inflammation.  One  year  later  she  became  the  victim  again 
of  indefinite  abdominal  pains,  with  distress  after  food,  in- 
creasing constipation  and  frequent  attacks  of  nausea,  as- 
sociated always  with  distressing  pain  in  the  right  side, 
not  far  from  the  site  of  the  old  scar.  A  careful  examination 
at  that  time  showed  the  right  kidney  to  be  prolapsed.  Ac- 
cordingly, she  submitted  again  to  an  operation,  which  con- 
sisted in  fixing  the  kidney  firmly  in  a  normal  position.  The 
operation  was  regarded  as  successful.  Six  months  later  her 
old  symptoms  recurred;  indeed,  they  had  never  entirely  sub- 
sided, except  as  she  lay  in  bed.  This  time  there  was  added 
to  the  former  distress  much  headache  and  attacks  of  what 
she  described  as  bilious  vomiting.  On  one  occasion  she 
was  jaundiced.  Again  she  entered  the  hospital,  and  for  the 
third  time  was  operated  upon.     The  abdomen  was  opened 

325 


326  SURGICAL    PROBLEMS. 

high,  a  few  adhesions  were  found  about  the  gall  bladder 
and  duodenum,  the  bile  ducts  were  explored,  but  nothing 
found,  and  the  gall  bladder  was  drained.  She  went  home, 
regarding  herself  as  cured,  but  three  months  later  she  was 
prostrated  again  with  an  exacerbation  of  her  former  symptoms 
to  which  were  now  added  deep  and  distressing  pelvic  pains, 
with  agonizing  dysmenorrhea.  For  the  fourth  time  she  en- 
tered the  hospital  and  was  operated  upon.  On  this  occasion 
her  pelvis  was  opened  from  above,  and  a  small,  cystic  left 
ovary  was  removed.  At  the  same  time  the  uterus  was  sus- 
pended. She  recovered  from  this  operation,  and  went  back 
home  to  take  up  her  usual  work  and  cares.  She  did  not  re- 
cover her  health,  however,  and  was  in  constant  misery, 
with  some  change  now  in  the  previous  symptoms.  The  dis- 
tress immediately  after  food,  and  the  nausea  persisted;  she 
was  troubled  with  a  constipation  so  obstinate  that  her  bowels 
were  moved  with  difficulty  not  more  than  once  a  week; 
there  was  great  and  continuous  flatulence  and  bloating 
and  almost  continual  pain  and  tenderness  in  the  epigastrium. 
Undismayed  by  the  failure  of  previous  operations  to  relieve 
her  symptoms,  the  patient  again  submitted  to  an'  explora- 
tory operation,  undertaken  with  a  view  to  breaking  up 
adhesions.  At  this  operation  a  few  adhesions  between  the 
stomach,  gall  bladder  and  duodenum  were  loosened  and  the 
abdomen  was  closed.  After  going  home  her  symptoms 
were  decidedly  relieved ;  her  nausea  and  much  of  her  general 
pain  disappeared,  though  her  constipation  was  as  bad  as 
ever.  In  a  short  time  a  new  series  of  pains  developed,  this 
time  in  the  region  of  the  splenic  flexure  and  sigmoid.  This 
pain  came  on  with  great  severity  whenever  she  walked 
about  and  occurred  occasionally  even  when  she  was  lying 
down.  She  took  to  her  bed  and  remained  there  until  the 
middle  of  February,  when  she  again  entered  the  Massachu- 
setts General  Hospital,  in  my  service. 

On  examining  Mrs.  Flanagan  I  found  her  to  be  a  well- 
developed  and  fairly  well-nourished  woman,  somewhat  hag- 
gard in  appearance  and  decidedly  despondent.  Her  thoracic 
organs  were  sound,  but  the  abdomen  presented  a  series  of  scars, 
as  one  would  expect.     The  pelvic  organs  were  in  good  posi- 


ABDOMINAL   ADHESIONS.  32/ 

tion  and  not  troublesome.  There  was  no  special  pain  or  ten- 
derness over  the  right  side  of  the  abdomen;  on  the  left  side, 
however,  there  was  marked  tenderness,  especially  on  light 
palpation  in  the  region  of  the  sigmoid,  and  tenderness  es- 
pecially marked  in  the  neighborhood  of  the  spleen.  There 
were  certain  features  about  her  anatomy  which  have  not  been 
previously  noted:  The  costo-iliac  space  was  extremely  nar- 
row, admitting  barely  a  single  finger  between  the  ribs  and 
the  crest  of  the  ilium;  when  she  stood  the  lower  portion  of 
the  abdomen  protruded  and  was  markedly  tympanitic; 
her  posture  was  stooping.  These  conditions,  together  with 
the  long  train  of  symptoms,  unrelieved  by  various  operations, 
suggested  the  possibility  of  a  general  intestinal  ptosis,  es- 
pecially when  one  considered  the  splenic  pain,  the  obstinate 
constipation  and  the  fact  that  she  had  been  operated  upon 
for  floating  kidney.  Accordingly,  we  had  taken  a  series  of 
bismuth  x-ray  plates.  These  plates  showed  at  once  a  de- 
cided abnormality  in  the  colon.  The  cecum  was  in  its 
proper  position,  but  the  ascending  colon  buckled  down  shortly 
after  rising  above  the  crest  of  the  ilium,  while  the  trans- 
verse colon  fell  into  the  pelvis,  and  as  it  rose  towards  the 
splenic  flexure  lay  so  close  to  the  descending  colon  that  it 
seemed  as  though  the  two  might  be  united  by  adhesions; 
the  splenic  kink  was  much  accentuated.  I  then  learned  a 
fact  which  is  characteristic  of  these  cases  of  splenic  obstruc- 
tion. I  was  told  that  the  patient's  stools,  which  were  passed 
with  difficulty,  were  of  the  nature  of  sheep's  dung,  the  masses 
being  small  and  round  like  marbles.  The  x-ray  plates 
also,  when  carefully  studied,  showed  the  bismuth  in  the  colon 
to  take  on  the  form  suggested  by  the  stools.  Accordingly, 
I  determined  on  an  exploration,  primarily  to  break  up  the 
possible  adhesions,  but  also  to  do  any  operation  which  seemed 
indicated  in  order  to  relieve  the  splenic  obstruction. 

On  opening  the  abdominal  cavity  I  found  few  or  no  ad- 
hesions anywhere  in  it.  The  transverse  colon  was  in  the 
position  in  the  pelvis  indicated  by  the  x-rays.  I  made  an 
anastomosis,  accordingly,  between  the  transverse  colon 
and  the  sigmoid,  where  the  two  loops  of  bowel  lay  together. 
I  then  followed  up  the  descending  colon,  with  the  purpose 


328  SURGICAL   PROBLEMS. 

of  excising  it,  together  with  the  distal  portion  of  the  trans- 
verse colon.  In  this  dissection  I  encountered  a  curious 
abnormality:  On  releasing  the  descending  colon  and  excis- 
ing it  up  to  and  beyond  the  splenic  flexure,  I  found  that  it 
plunged  deeply  towards  the  median  line  and  apparently 
disappeared  beneath  the  mesentery  of  the  small  intestine. 
Leaving  the  dissection  at  that  point,  I  then  cut  off  the  distal 
portion  of  the  transverse  colon  beyond  the  anastomosis 
and  excised  it  in  turn.  On  tracing  it  up  through  the  abdomen, 
I  discovered  that  it  joined  the  descending  colon  beneath 
the  mesentery  of  the  small  intestine,  as  I  have  already  in- 
dicated. The  whole  excised  loop,  on  being  freed  from  its 
attachments,  was  then  found  to  lie  completely  encircled  by 
an  apparent  rent  in  the  mesentery  of  the  small  intestine,  so 
that  I  could  draw  it  back  and  forth  through  the  hole  or  bridge 
formed  by  this  mesentery.  Such  a  condition  is  certainly 
extraordinary  and  almost  unaccountable.  I  removed  the 
loop  of  large  intestine,  leaving  the  anastomosis  between  the 
sigmoid  and  transverse  colon  to  carry  the  fecal  stream. 

The  patient  had  a  stormy  convalescence,  but  rallied  gradu- 
ally, so  that  in  the  course  of  two  weeks  she  was  out  of  danger. 
The  operation  apparently  was  all  that  was  needed  to  relieve 
the  intestinal  obstruction  and  to  establish  normal  action  of 
the  bowels.  The  left-sided  pain  disappeared,  and  the  patient's 
condition  at  last  accounts  was  satisfactory.^ 

^  In  reviewing  this  case  and  summing  up  the  series  of 
operations  and  disablements  from  which  the  patient  suffered 
it  is  fairly  obvious  that  her  trouble,  from  the  beginning, 
was  due  to  a  congenital  ptosis  of  the  transverse  colon,  asso- 
ciated with  the  remarkably  abnormal  course  of  that  viscus 
through  and  beneath  the  mesentery  of  small  intestine. 
This  peculiar  position  of  the  gut  obviously  accounts  for  the 
gradually  increasing  obstruction,  which  I  believe  now  was 
undoubtedly  the  one  and  only  cause  of  the  patient's  sufferings. 


ABDOMINAL   ADHESIONS.  329 

Case  99.  Probably  no  region  of  the  body  offers  more 
opportunities  for  difficult  diagnosis,  and  for  errors  in  diag- 
nosis, than  does  the  abdominal  cavity,  especially  when  we 
reflect  that  not  infrequently  thoracic  disease  is  mistaken 
for  abdominal  disease. 

On  the  15th  of  January,  1909,  I  was  asked  to  go  to  a 
neighboring  college  town  to  see  in  consultation  a  young  woman 
student.  She  was  nineteen  years  of  age,  and  I  secured  the 
following  history:  She  was  one  of  six  children.  Her  father 
died  by  accident  several  years  before  I  saw  her,  but  her  mother 
was  still  living,  and  was  a  pronounced  neurasthenic  invalid; 
that  is  to  say,  since  becoming  the  mother  of  many  children 
she  had  developed  marked  dyspeptic  symptoms,  was  the  vic- 
tim of  headaches,  and  spent  much  of  her  time  in  bed  or  on 
the  sofa,  without  relief  from  medicine  or  medical  care.  The 
girl  student  whom  I  saw  had  suffered  in  childhood  from 
measles,  scarlatina  and  whooping-cough,  but  in  general  had 
always  been  regarded  as  well,  though  her  digestion  was  not 
particularly  strong,  and  even  up  to  the  age  of  fourteen 
she  vomited  easily  after  a  hearty  meal.  Nevertheless,  she 
had  grown  up  a  robust  girl,  was  active  in  body  and  mind^ 
and  entered  college  at  the  age  of  seventeen.  Four  years 
before  I  saw  her,  while  coasting,  she  received  a  severe  blow 
on  the  right  side  of  the  abdomen,  which  laid  her  up  with 
pain  and  soreness  for  some  two  weeks.  One  year  later,  or 
three  years  before  my  visit,  she  had  symptoms  of  appendi- 
citis, —  tenderness  in  the  region  of  the  appendix,  unusual 
constipation,  nausea,  and  on  two  occasions  a  slight  rise  of 
temperature.  Her  family  physician  in  the  country  made 
the  diagnosis  of  appendicitis  in  the  year  of  1906,  and  removed 
the  appendix,  announcing  after  its  examination,  "  chronic 
interstitial  appendicitis."  The  patient  went  on  without 
disturbance  for  two  years  thereafter,  but  in  1908  she  began 
to  suffer  from  recurring  attacks  of  frequent  severe  pain  about 
the  appendix  wound.  So  distressing  did  these  become  that 
her  physician  again  operated.  On  the  occasion  of  my 
seeing  the  girl,  I  talked  with  him  over  the  telephone,  and 
learned  that  at  the  second  operation  he  found  the  omentum 
glued    against    the    anterior   abdominal    wall,    but    nothing 


330 


SURGICAL    PROBLEMS. 


more  that  was  abnormal.  He  loosened  the  omentum,  but 
no  special  relief  followed.  The  attacks  of  pain  continued  at 
varying  intervals.  In  November,  two  months  before  I 
saw  the  patient,  she  was  taken  with  an  unusually  severe 
attack  of  abdominal  pain,  and  sent  for  the  college  physician. 
This  gentleman  found  her  in  great  distress,  with  a  tempera- 
ture of  99°,  distention,  nausea  and  occasional  vomiting; 
in  other  words,  symptoms  suggesting  an  intestinal  obstruc- 
tion. She  recovered,  however,  under  rest  and  careful  medi- 
cation, and  was  perfectly  well  until  the  day  before  my  visit. 
On  that  day,  January  14,  1909,  she  suffered  again  from  an 
acute  attack  of  abdominal  pain,  with  vomiting.  Her  tem- 
perature rose  to  100°,  but  her  pulse  remained  steady  at  80. 
At  that  time  there  was  slight  abdominal  distention,  which 
was  relieved  by  calomel  and  Epsom  salts.  Six  hours  later, 
however,  there  was  another  attack  of  pain,  localized  espe- 
cially at  the  site  of  the  old  appendix.  The  temperature  rose 
to  101°,  the  pulse  to  90,  and  there  was  every  evidence  of 
an  acute  obstruction.^  The  physician  in  the  case  was  obliged 
to  resort  to  morphia,  which  he  gave  in  quarter-grain  doses 
three  times  before  he  was  able  to  relieve  the  patient's  dis- 
tress. Six  hours  after  the  last  dose,  that  is  to  say,  at  eleven 
in  the  morning  of  the  15th  of  January,  I  saw  her. 

She  appeared  as  a  robust,  florid  girl;  her  weight  was  one 
hundred  and  fifty-four  pounds,  and  she  did  flot  look  very  ill. 
Her  whole  abdomen  was  slightly  tender,  but  especially  tender 
one  inch  above  the  middle  of  the  old  appendix  scar. 
Deep  palpation  was  impossible,  in  spite  of  the  morphia. 
She  was  also  excessively  tender,  superficially,  all  about  the 
scar.^ 

In  view  of  the  recurring  attacks  of  obstruction  and  their 
increasing  severity,  it  seemed  to  me  that  we  were  justified 
in  performing  an  exploratory  operation.  Accordingly,  I 
had  the  patient  removed  to  a  Boston  hospital,  which  she 
reached  the  next  day  in  much  improved  condition.  One 
day  later  I  operated,  with  the  patient  under  gas  and  oxygen 
anesthesia.  I  excised  the  old  scar  and  opened  the  abdominal 
cavity,  when  there  appeared  at  once  a  great  mass  of  dense 
adhesions  extending  in  various  directions.     One  stout  ad- 


ABDOMINAL    ADHESIONS.  33 1 

hesion  especially  tied  the  caput  ceci  against  the  pelvis, 
another  extended  from  the  pelvis  to  the  transverse  colon 
and  held  that  viscus  down  against  the  pubes;  the  omentum 
also  was  wrapped  tightly  about  the  caput.  In  other  words, 
here  were  conditions  difficult  and  formidable  enough  to 
account  for  the  attacks  of  obstruction.^ 

^  Severe  attacks  of  abdominal  pain  in  a  young  person, 
associated  with  evidence  of  obstruction,  suggested  a  variety 
of  serious  conditions.  Perhaps  the  most  common  is  intus- 
susception; volvulus,  in  cases  of  a  colon  with  a  congenitally 
long  mesentery,  may  occur;  not  infrequently  one  finds  inter- 
nal hernia,  especially  in  the  retrocecal  pouch  and  in  the 
duodenal  fossa;  then  there  is  always  the  possibility  of  ob- 
struction by  a  band  or  adhesions  following  an  operation. 
In  the  case  of  our  present  patient  the  pain,  always  localized 
in  the  right  inguinal  region,  suggested  intussusception,  hernia 
and  strangulation  by  a  band. 

^  Superficial  tenderness  about  the  site  of  an  old  scar  is 
common.  Frequently  it  is  assumed  to  be  due  to  a  neurotic 
condition.  In  more  than  one  case  I  have  found  it  to  be  due 
to  a  persistent  neuritis,  and  have  relieved  the  pain  by  re- 
secting neighboring  nerves.  In  the  case  of  abdominal  ad- 
hesions in  the  neighborhood  of  an  old  operation,  superficial 
tenderness  is  frequently  seen,  though  the  cause  of  such  ten- 
derness is  not  altogether  apparent. 

^  Various  observers  have  reported  cases  of  extensive 
adhesions  associated  with  old  operations.  Sometimes  such 
adhesions  are  formidable  and  dangerous;  sometimes  they  are 
harmless  enough.  It  is  worthy  of  note  that  the  most  serious 
adhesions  are  apt  to  be  those  associated  with  intestinal 
ptosis,  since  the  adhesions  when  formed  readily  tie  down 
and  obstruct  the  displaced  bowel.  The  question  is  often 
asked  —  Why  free  adhesions,  when  they  are  sure  to  form 
again?  The  answer  to  this  query  rests  in  the  fact  that  the 
great  majority  of  adhesions  do  no  special  harm  and  rarely 
cause  pain.  When  disturbing  and  painful  adhesions  do 
exist,  they  should  properly  be  broken  up,  even  though  the 
formation  of  secondary  adhesions  is  inevitable,  because  of 
the  chance  that  the  secondary  adhesions  will  so  form  as  to 
group  themselves  in  the  harmless  and  painless  class.  The 
value  of  Cargile  membrane  as  a  preventive  of  adhesions 
is  questionable.  I  did  not  use  it  in  this  case;  I  have  used  it 
in  other  cases.  I  have  been  unable  to  see  that  it  makes  any 
special  difference  in  the  after-condition  of  the  patient. 


332  SURGICAL   PROBLEMS. 

No  sign  of  the  appendix  was  found.  The  abdomen  was 
closed  tightly,  without  drainage,  and  the  patient  was  returned 
to  bed  in  excellent  condition,  where  she  promptly  recovered 
from  the  anesthetic  without  shock  and  without  special 
discomfort. 

The  encouraging  fact  about  the  case  is  that  the  operation 
entirely  relieved  the  patient  of  her  symptoms.  Two  years 
later  I  heard  from  her  physician,  who  reported  that  she  con- 
tinued in  excellent  health,  was  robust,  vigorous  and  athletic, 
and  had  no  further  evidence  of  abdominal  disturbance. 


GENITO-URINARY. 

Case  100.  Deacon  McQuestion,  of  Horse  Heads,  was 
seventy-three  years  old  when  he  suffered  a  sudden  and  serious 
illness,  in  November,  1909.  Even  at  his  advanced  age  he 
persisted  in  following  his  calling  as  a  traveling  salesman,  and 
it  was  on  one  of  his  trips  to  New  York  for  a  firm  of  Boston 
importers  that  he  became  acutely  ill. 

This  patient's  previous  history  had  been  in  no  way  re- 
markable, so  far  as  I  could  get  at  it.  He  married  young, 
and  was  the  father  of  two  middle-aged  daughters.  He  had 
always  been  well,  so  he  said,  except  for  a  chronic  eczema 
which  troubled  him  much  during  middle  life.  He  had  not 
missed  a  day  from  his  work  for  forty  years,  and  with  the 
advance  of  old  age  suffered  merely  from  general  weakness 
and  lassitude,  was  easily  tired  and  had  a  rather  small  appetite. 
He  had  never  suffered  from  renal  or  bladder  disease,  and 
his  eyes  were  remarkably  bright  and  piercing.  Regarding 
his  immediate  illness,  he  told  this  story :  He  was  in  New  York, 
and  took  the  five  o'clock  afternoon  train  to  return  to  Boston, 
where  he  had  lodgings.  While  on  the  train,  halfway  from 
New  York,  he  suddenly  experienced  a  great  desire  to  mic- 
turate, but  on  endeavoring  to  empty  his  bladder  found  that 
the  stream  was  obstructed,  so  that  he  could  pass  but  a  few 
drops  only.  Greatly  alarmed,  he  walked  the  car  for  nearly 
two  hours,  endeavoring  every  few  minutes  to  empty  his 
bladder.  With  the  passage  of  time,  pain  in  the  bladder  came 
on  and  increased,  so  that  when  he  reached  Boston  he  was  in 
a  state  of  collapse.  He  was  lifted  from  the  train,  put  into 
a  cab  and  driven  to  his  lodgings,  where  he  summoned  his 
physician.  The  physician  told  me  later  that  Mr.  McQues- 
tion's  condition  puzzled  him  extremely.  On  reaching  him 
shortly  before  midnight,  he  expected  to  find  the  cause  of 
the  obstruction  to  be  an  enlarged  prostate,  but  on  examining 
that  organ  by  the  rectum  he  could  discover  a  prostate  of  only 
moderate  size,  which  did  not  seem  to  account  for  the  obstruc- 

333 


334  SURGICAL    PROBLEMS. 

tion.  He  then  endeavored  to  pass  a  sound,  but  could  advance 
it  to  the  triangular  ligament  only.  Then  he  used  a  number 
of  stiff  catheters,  but  after  the  second  attempt  drew  nothing 
but  blood.  In  the  mean  time  the  patient  was  suffering  greatly, 
and  was  relieved  by  morphia.  As  it  was  now  two  o'clock 
in  the  morning,  with  the  patient  exhausted  and  the  physician 
in  increasing  anxiety,  he  sent  for  me  to  assist  him. 

It  was  clear  to  me,  on  seeing  the  patient,  that  the  first 
thing  to  do  was  to  empty  the  bladder,  and  as  it  was  obvious 
that  false  passages  in  the  urethra  existed,  and  that  the  pas- 
sage of  a  catheter  might  be  impossible,  I  aspirated  the  bladder 
above  the  pubes  and  drew  off  about  fifty  ounces  of  urine, 
which  proved  to  be  of  fair  quality,  and  showed  on  careful 
examination  the  existence  of  senile  kidneys  merely.  The 
next  day,  with  the  patient  under  anesthesia,  I  endeavored 
to  find  a  passage  through  his  urethra,  but  was  unable  to  do 
so,  owing  to  the  presence  of  a  false  passage.  At  the  same 
time,  on  examining  the  prostate,  in  my  turn,  I  could  see 
little  reason  why  it  should  have  caused  so  pronounced  an 
obstruction.  Accordingly,  I  determined  to  drain  the  bladder 
from  above,  and  so  allow  the  urethra  to  heal.  With  supra- 
pubic drainage  established,  the  patient's  symptoms  were 
completely  relieved  for  a  time,  and  he  went  on  apparently 
to  convalescence.  A  week  later,  on  a  more  careful  examina- 
tion of  the  urethra,  it  was  evident  that  the  obstruction  was 
due,  in  part  at  least,  to  an  old,  organic  stricture  of  large  cali- 
ber, which  accounted  for  the  difficulty  of  my  consultant 
in  penetrating  to  the  bladder,  and  for  the  formation  of  the 
false  passages. 

Nevertheless,  the  patient  did  not  improve.  He  began 
to  suffer  acutely  from  headaches,  for  which  the  state  of  his 
urine  did  not  account;  his  eyesight  began  to  fail  and  his 
digestion  became  greatly  disturbed.  Almost  all  food  nau- 
seated him,  and  he  Endeavored  to  vomit  occasionally  even 
with  the  stomach  empty.^  The  situation  appeared  alarming. 
Repeated  examinations  of  the  urine  showed  it  to  be  in  no 
great  degree  peculiar ;  the  suprapubic  wound  was  closing  well, 
and  a  soft  catheter  was  admitted  readily  by  the  urethra. 
At  the  end  of  two  weeks  the  suprapubic  wound  was  prac- 


GENITO-URINARY.  335 

tically  healed,  and  the  patient  had  been  able  for  two  or  three 
days  at  that  time  to  void  urine  vohintarily.  One  night, 
however,  on  attempting  to  void,  he  found  himself  incapable 
of  passing  any  water.  Immediately  he  became  alarmed, 
anticipating  a  recurrence  of  his  retention.  I  was  sent  for,  and 
on  learning  that  no  urine  had  been  passed  for  ten  hours 
I  succeeded  without  difficulty  in  emptying  the  bladder  by 
means  of  a  soft  rubber  catheter.  Another  week  went  by. 
The  patient's  general  health  was  becoming  greatly  impaired; 
his  headaches  were  more  frequent  and  racking;  and  his  eyes 
began  to  give  him  the  greatest  trouble,  with  blurring  of  vision 
and  almost  total  inability  to  read  coarse  print.  Accordingly, 
I  had  an  examination  of  his  eye-grounds  made,  when,  much 
to  my  interest,  my  previous  suspicions  of  intracranial 
trouble  were  confirmed  by  the  discovery  of  bilateral  choked 
disk,  of  moderate  degree.  It  was  evident,  therefore,  that 
the  patient  was  suffering  from  some  form  of  intracranial 
tension,  and  the  most  probable  suggestion  was  brain  tumor. 
On  carefully  discussing  with  him  his  previous  health,  I  then 
learned  for  the  first  time  that  some  fifteen  years  previously 
he  had  suffered  for  a  short  time  from  what  apparently  was 
syphilis,  and  syphilis  innocently  contracted.  If  he  had  a 
primary  lesion  at  all,  it  was  on  the  lip.  He  had  had  enlarged 
lymph-nodes  of  the  neck  and  a  fairly  active  skin  eruption, 
but  under  proper  treatment  his  symptoms  disappeared  and 
he  regarded  himself  as  well,  although  the  treatment  was 
continued  for  some  nine  months  only.  Our  problem  was  now 
approaching  solution,  and  I  was  forced  to  the  conclusion 
that  the  underlying  difficulty  with  the  patient  was  a  brain 
tumor,  presumably  a  syphiloma  or  gumma.  ^ 

^  Up  to  this  point  in  the  history  of  this  patient's  illness 
various  questions  arise  which  demand  answers:  Why  should 
an  apparently  non-obstructing  prostate,  or  a  stricture  of  large 
caliber,  have  caused  a  sudden  retention?  What  measures 
should  the  attending  physician  have  taken  in  order  to  es- 
cape the  making  of  false  passages?  Why  should  a  brief 
period  of  retention,  followed  by  satisfactory  and  permanent 
drainage,  have  become  associated  with  increasing  and  rack- 
ing headaches?  These  three  questions  are  in  a  sense  inter- 
dependent.    Careful  reflection  convinces  one  that  we  must 


336  SURGICAL   PROBLEMS. 

look  beyond  the  local  conditions  for  the  cause  of  the  reten- 
tion. The  attending  physician  should  have  avoided  the 
use  of  stiff  catheters,  and  have  employed  soft  rubber  catheters 
only  to  empty  the  bladder.  The  headaches  suggest,  —  uremia, 
a  local  neuralgia,  disease  within  or  without  the  skull  box 
proper,  digestive  disturbances,  general  disease,  especially 
suppurative  disease. 

2  The  trilogy  of  symptoms, —  headache,  choked  disk  and 
vomiting,  suffices  for  the  establishment  of  the  diagnosis 
hrain  tumor  usually.  At  any  rate,  when  persistently  present, 
they  indicate  a  progressive  rise  of  intracranial  tension. 
The  practitioner  must  not  forget,  however,  that  a  neoplasm, 
a  brain  tumor  of  the  organic  type,  may  exist  within  the  skull 
of  a  person  the  victim  of  syphilis.  We  are  all  familiar  with 
the  fact  that  the  active  administration  of  iodide  of  potash 
will  relieve  many  cases  of  so-called  brain  tumor.  This  is  be- 
cause the  tumor  is  of  syphilitic  origin,  and  the  iodide  of  potash 
reduces  the  syphiloma.  One  cannot  too  often  repeat  the 
warning,  however,  that  persistence  in  the  use  of  iodide  of 
potash  without  marked  improvement  in  the  symptoms 
is  extremely  dangerous.  The  suspected  tumor  may  not 
be  syphilitic;  therefore  the  iodide  of  potash  is  without  benefit. 
Furthermore,  a  densely  encapsulated  gumma  may  not  yield 
to  anti-syphilitic  remedies,  so  that  the  failure  of  the  iodide 
of  potash  to  improve  the  condition  does  not  mean  necessarily 
that  the  disease  is  non-syphilitic.  It  is  a  good  general 
rule  to  drop  the  iodide  and  proceed  to  operation  for  the  relief 
of  the  symptoms  in  case  the  iodide  has  failed  to  improve  the 
patient's  condition  after  a  lapse  of  two  —  at  the  most,  of 
three  —  weeks. 

This  brain  disease  undoubtedly  had  inhibited  the  action 
of  the  bladder,  so  that  the  distention  from  which  the  patient 
suffered  on  his  railway  trip  was  due  to  a  lesion  of  central 
origin,  and  not  to  the  local  obstruction  which  was  at  first 
suspected. 

I  immediately  instituted  a  course  of  iodide  of  potash  for 
Mr.  McQuestion,  and  pushed  it  vigorously,  running  it  up 
in  a  few  days  to  ninety  grains  a  day.  Somewhat  to  my  sur- 
prise, the  result  was  satisfactory.  By  the  end  of  ten  days 
his  headaches  had  greatly  diminished  in  violence  and  in  fre- 
quency, his  nausea  had  subsided,  and  the  condition  of 
choked  disk  was  materially  improved.  By  the  end  of  a  month 
all  his  symptoms  were  so  much  better  that  I  regarded  him  as 


GENITO-URINARY.  337 

practically  well.  Coincident  with  the  improvement  in  his 
head  symptoms,  the  state  of  the  bladder  improved  also. 
He  had  no  longer  any  tendency  to  retention,  and  after  the 
passage  of  a  few  sounds  the  slight  stricture  ceased  to  trouble 
him  at  all.  This  patient  has  been  under  my  observation  now 
for  some  sixteen  months.  He  still  takes  iodide  of  potash 
in  small  daily  doses;  his  general  condition  is  excellent,  and 
in  spite  of  his  advanced  age  and  laborious  life  there  seems 
good  reason  to  believe  that  he  will  live  for  several  years  to 
come. 


DIAGNOSES. 


Case. 

1.  Retroperitoneal  hernia  (duodenal  ulcer). 

2.  Pyloric  obstruction. 

3.  Pyloric  obstruction. 

4.  Duodenal  ulcer. 

5.  Pyloric  obstruction. 

6.  Appendicitis. 

7.  Cancer  of  the  stomach. 

8.  Carbuncle  of  the  lip. 

9.  Ovarian  cyst  (epilepsy). 

10.  Stenosis  of  os  uteri  (epilepsy). 

11.  Sarcoma  of  kidney. 

12.  Perforating  wound  of  abdomen. 

13.  Undeveloped  uterus,  stenosis  of  os. 

14.  Cancer  of  breast. 

15.  Fibro-cystic  tumor  of  breast. 

16.  Cancer  of  breast. 

17.  Spasm  of  sphincter  ani. 

18.  Spasm  of  pylorus  and  of  sphincter  ani. 

19.  Debility,  and  spasm  of  sphincter  ani. 

20.  Constipation,  and  spasm  of  sphincter  ani. 

21.  Duodenal  ulcer. 

22.  Duodenal  ulcer. 

23.  Duodenal  ulcer. 

24.  Myoma  uteri;   retroversion. 

25.  Salpingitis  (pneumonia). 

26.  Procidentia. 

27.  Concussion  of  brain. 

28.  Fracture  of  base  of  skull. 

29.  Concussion  of  brain  with  loss  of  memory. 

30.  Fracture  of  base  of  skull. 

31.  "  Surgical  kidney." 

32.  Chronic  pyonephrosis. 

33.  Acute  hematogenous  infection  of  kidney  (pneumonia). 

34.  Acute  empyema. 

35.  Empyema  (abdominal  symptoms). 

36.  Fibrous  stricture  of  rectum  (recto-vaginal  fistula). 

37.  Fracture  of  forearm  (mal-union). 

38.  Fracture  of  forearm. 

39.  Subperiosteal  hematoma. 

40.  Inguinal  hernia. 

41.  Umbilical  hernia. 

42.  Multiple  herniae. 

43.  Infected  gall  bladder. 

339 


340  DIAGNOSES. 

Case. 

44.  Stones  in  gall  bladder. 

45.  Disease  of  bile  passages  and  appendix  (syphilis). 

46.  Disease  of  bile  passages. 

47.  Stones  in  gall  bladder. 

48.  Cancer  of  liver. 

49.  Tubal  pregnancy. 

50.  Hemosalpinx. 

51.  Enteroptosis. 

52.  Enteroptosis,  arthritis,  pleurisy,  endocarditis. 

53.  Enteroptosis. 

54.  Ptosis  of  abdominal  and  pelvic  viscera. 

55.  Enteroptosis,  nephroptosis. 

56.  Enteroptosis. 

57.  Gastro-enteroptosis. 

58.  Gastro-enteroptosis. 

59.  Gastro-enteroptosis,  arthritis  (double  cataract). 

60.  Gastro-enteroptosis,  nephroptosis. 

61.  Ptosis  of  abdominal  viscera. 

62.  Gastro-enteroptosis. 

63.  Enteroptosis. 

64.  Ptosis  of  abdominal  and  pelvic  viscera. 

65.  Goiter  (syphilis). 

66.  Cystic  goiter;  cancer  of  uterus. 

67.  Acute  Graves'  disease. 

68.  Graves'  disease. 

69.  Graves'  disease;  enteroptosis. 

70.  Graves'  disease. 

71.  Graves'  disease. 

72.  Graves'  disease. 

73.  Chronic  appendicitis. 

74.  Chronic  appendicitis. 

75.  Chronic  appendicitis;  myoma  of  uterus. 

76.  Acute  appendicitis  (diabetes). 

77>  Acute  appendicitis;   diffuse  peritonitis. 

78.  Chronic  appendicitis  (typhoid  fever). 

79.  Acute  appendicitis  (osteomyelitis  of  femur). 

80.  Chronic  appendicitis. 

81.  Acute  abdominal  infection  unexplained. 

82.  Acute  metritis  and  salpingitis. 

83.  Myoma  of  uterus,  visceral  ptosis. 

84.  Myoma  of  uterus. 

85.  Retroversion  of  uterus  (malingering). 

86.  Myoma  of  uterus. 

87.  Sloughing  fibroid  of  uterus;   peritonitis. 

88.  Intestinal  obstruction  from  ptosis. 

89.  Pelvic  hematocele. 

90.  Ovarian  cyst;  twisted  pedicle. 

91.  Large  ovarian  cyst. 

92.  Salpingitis,  pernicious  vomiting  of  pregnancy. 


DIAGNOSES.  341 


Case. 


93.  Periproctitis. 

94.  Ulcer  of  rectum. 

95.  Fistula  in  ano;  gonorrhea. 

96.  Tuberculous  testis. 

97.  Gonorrheal  epididymitis. 

98.  Abdominal  adhesions;   multiple  operations;  visceral  ptosis. 

99.  Abdominal  adhesions. 

100.  Retention  of  urine;  gumma  of  brain. 


INDEX. 


Abdomen,  attic  of,  58. 

boat  shaped,  2x7. 

perforated,  41-43. 

scaphoid,  144. 
Abdominal,  267-282. 

adhesions,  325-332. 

distention,  general,  174. 

operations  in  very  young  children, 
186. 

pain,  173. 

constant,  aggravated  by  food,  159. 
general,  109. 
indefinite,  325. 
recurring  attacks  of,  190. 

sinus,  257. 

supports,  250. 
Abortion,  induced,  302. 

tubal,  153,  157. 
Absorption   of    water   from   the    fecal 

stream,  186. 
Acid  dyspepsia,  74. 

gastritis.  73. 
Acute  appendicitis,  24,  245,  246,  305. 

cholangitis,  132. 

gastric  ulcer,  20. 

gonorrhea,  322. 

Graves'  disease,  209,  215. 

hemorrhoids,  306. 

infarct,  hemorrhagic,  of  the  kidney, 
105. 
septic  hematogenous,  99. 

infection,  29. 

pancreatitis,  136. 

septicemia,  105. 
Adhesions,  abdominal,  325-332. 

deep  in  the  peMs,  269. 

obstructing,  330. 
Anal  fistula,  313. 
Analysis  of  stools.  159. 
Anastomosing  cecum  to  sigmoid,  161. 
Anemia.  69,  275. 

secondarv-,  38. 
Anesthesia,  80. 

ether,  122. 


gas  and  oxygen,  330. 

nitrous  oxide  and  oxygen,  80,   125, 
245,  246,  281,  330. 

prostration  of  ether,  246. 

spinal,  123. 
Angle,  costovertebral,  10,  11,  105,  310. 
Antacid  treatment,  299. 
Anterior  fossa,  87. 

gastro-enterostomy,  26. 

splints,  113. 
Anti-malarial  treatment,  39. 
Anti-syphilitic  remedies,  336. 
Anus,  artificial,  1 12. 
Apoplexy,  pancreatic,  153. 
Appendicostomy,  182. 
Appendicitis,     190,     195,     233,     250, 
253,  254,  257,  302. 

and  bile  passage  disease  associated, 

138- 

acute,  24,  245,  246,  305. 

chronic,  18,  160,  236,  239. 

symptoms,  17. 
Appendix,  14,  233. 

blood  supply  of,  182. 

perforation  of,  153. 
Appetite,  morning  lack  of,  123. 

lack  of,  for  breakfast,  188. 
Apprehension,  227. 
Area,  motor,  87. 
Arteries,   ligation  of  superior  thyroid, 

229,  230. 
Arthritis,  165,  179,  182,  185,  246.  308. 
Artificial  anus,  112. 
Attacks,  bilious,  69,  131. 

of  abdominal  pain,  recurring,  190. 
Axilla,  nodes  in,  47. 
Bacilli,  Oppler-Boas,  24. 
Base,  fracture  of,  86,  87. 
Bath,  Turkish,  322. 
Beebe  and  Rogers,  227,  228. 
Belt,  corset-,  169,  201,  289. 

ptosis,  197. 
Belly,  agonizing  pain  in,  152. 
Bellyache,  20. 


343 


344 


INDEX. 


protracted,  250. 
Benign  tumors,  48. 
Bidet  douche,  307. 
Bile  passage  disease,  171. 

and  appendicitis  associated,  138. 

pain  of  malignant,  136. 

drainage  of,  139. 
Bilious  attacks,  69,  131. 

vomiting,  275. 
Biting  of  tongue,  31. 
Bladder,  322. 

hemorrhage  from,  37. 
Bleeding  from  ears,  87. 

from  mouth,  87. 
Blindness,  185. 

headache  and  vomiting;    "  trilogy," 
86. 
Bloating,  193. 
Blood,  from  rectum,  19,  20. 

in  stools,  66. 

occult,  236. 

supply  of  appendix,  182. 

vomiting  of,  19. 
Bloody  urine,  37,  42. 
"  Blues,"  234. 

Blurring  of  vision,  14,  50,  160. 
Bolting  food,  191. 
Bone  cyst,  118,  119. 

disease,  257. 

petrous,  87. 
Bones,  113-119. 

of  forearm,  114. 
Borderland,  259-267. 
Boston  Medical  and  Surgical  Journal, 

12. 
Bowel,  The,  305-315- 

casts  of,  161. 

rupture  of,  153. 
Brain, 

laceration  of,  87. 

tumor,  335,  336. 
Breakdown,  nervous,  178. 
Breast,  The,  47-53. 

lump  in,  47. 

tumors,  nature  of,  48. 
Breath,  shortness  of,  160,  203. 
Breathing,  stertorous,  85,  86. 
Cabot,  A.  T.,  38. 

R.  C,  38. 
Calcium  chloride,  149, 


lactate,  149. 
Calculus,  renal,  99. 

ureteral,    105,    157,  309;  impacted, 
261. 
Callus,  113. 

Calomel,  salts  and,  250. 
Cancer,  257. 

of  stomach,  24,  26. 

inoperable,  53. 
Capsule,  stripping  the  posterior,  214. 
Carbuncle,  30. 

of  upper  lip,  30. 
Carcinoma,  208. 
Cargile  membrane,  331. 
Carlsbad  salts,  69. 
Casts  of  bowel,  161. 
Catheter,  stiff,  336, 

soft  rubber,  336. 
Causes  of  hematuria,  38. 
Cecum,  anastomosing,  to  sigmoid,  161. 

mass  in  region  of,  236. 
Center,  respiratory,  compression  of,  86. 

vasomotor,  irritation  of,  86. 
Cervical  stump,  suspension  of,  270. 

triangle,  47. 
Cervix,  78. 
Childbirth,  270. 
Children,     abdominal     operations     in 

very  young,  186. 
Chloride,  calcium,  149. 
Cholangitis,  135. 

acute,  132. 
Cholecystectomy,  142. 
Cholecystostomy,  139. 
Christian  Science,  52. 
Chronic  appendicitis,  18,  160,  236,  239. 

constipation,  81,  168,  235. 

diarrhea,  186. 

duodenal  ulcer,  123. 

dyspepsia,    69,    82;    indefinite,    165; 
182,296. 

gastric  ulcer,  20. 

indigestion,  233-241. 

inflammation  of  gall  bladder,  141. 

intestinal  obstruction  in  young  per- 
sons, 289, 

irritability,  82. 

jaundice,  149. 

malaria,  38. 

pancreatitis,  149, 


INDEX. 


345 


toxemia,  165. 
Circulation,  178. 
Coagulation  time,  149. 
Cocaine,  222,  230. 
Colectomy,  186,  289. 
Colitis,  mucous,  31,  32,  161,  179,  182. 
Colon,  abnormality  of,  289. 

crumpled,  196. 

descent  of  ascending,  171. 

extirpation  of,  289. 

flushing  the,  182. 

prolapsed,  168. 

x-rays  of  stomach  and,  274. 
Colonic  kink,  175. 
Colostomy,  112,  186. 
Collapse,  22,  152,  157,  333. 
Coma,  86. 

Compression  of  respiratory  center,  86. 
Congenital  gastro-enteroptosis,  165. 

ptosis,  loi,  274,  328. 
Consciousness,  loss  of,  31. 
Constipation,  chronic,  81,  168,  235. 

scybalous,  196. 
Contracture,  Volkmann's,  114. 
Convulsion,  epileptiform,  31,  32. 

Jacksonian,  90. 
Cord,  twisted,  317,  319. 
Corrosive  sublimate  vaginal  douches, 

308. 
Corset,  tight,  178. 
Corset-belt,  169,  201,  289. 
Cortical  damage,  86. 
Costal  pain  below  right  costal  margin, 

262. 
Costovertebral  angle,  10,  11,  105,  310. 
Crile,  G.  W.,  82,  213,  217,  222,  223. 
Crises,  Dietl's,  17I0 
Cuba,  37. 
Curette,  199. 

Cutting  the  ovarian  nerves,  294. 
Cutting  short  pregnancy,  302. 
Cyst,  bone,  118,  119. 

dermoid,  297. 

meningeal,  91. 

ovarian,  strangulated,  297. 
twisted,  157. 

tubo-ovarian,  240. 
Cystadenoma,  fibro,  50. 

papillary,  51. 


Cystic    degeneration    of    hyperplastic 
goiter,  227. 

goiter,  204. 

ovary,  274. 
Cystitis,  99,  322. 
Cystocele,  275. 

Cystoscopic  examination,  311. 
Damage,  cortical,  86. 

to  diseased  kidneys,  246. 
Davis,  Lincoln,  311. 
Decline,  gradual,  275. 
Decompression,  94. 
Degeneration,    cystic,    of   hyperplastic 

goiter,  227. 
Delirious,  244. 
Delivery,  mechanics  of,  284. 
Depressant,  ether  a,  80. 
Depression,  173. 

mental,  175. 
Dermoid  cyst,  297. 
Diabetes,  246. 
Diarrhea,  chronic,  186. 
Diet,  fatty,  178. 
Dietl's  crises,  171. 
Diffuse  peritonitis,  109. 
Digestive  disorders,  55-64,  159-162. 
Diplococcus,  314. 
Diphtheria,  131. 
Discomfort  In  epigastrium,  193. 
Disease,  bile  passage,  171. 

and  appendicitis  associated,    138. 
pain  of  malignant  disease  of,  136. 

bone,  257. 

enteroptosis    and    Graves',    relation 
between,  217. 

Graves',  50,  203,  204,  207,  210,  213, 
216,    220,    222,    223,    226,    227, 
228, 273, 281. 
acute,  209. 
symptoms  of,  221. 

intestine,  malignant  disease  of,  236. 

liver,  malignant  disease  of,  149. 

pelvic,  source  of,  297. 

sacro-iliac,  308. 

scrotum,  within,  high  operation  for, 

323- 
thoracic,  1 10. 
tubal,  294. 
venereal,  313. 


346 


INDEX. 


Diseased  kidney,  damage  to,  246. 

tubes,  80. 
Disk,  choked,   86,  335,  and  headache 

and  vomiting,  336. 
Distention,  abdominal,  general,  174. 
Distress  immediately  after  eating,  134. 

gastric,  24. 
Disturbance,  mental  and  nervous,  280. 
Diverticulitis,  109,  123,  157,  250,  310. 
Dizzy  spells,  34,  35. 
Douche,  Bidet,  307. 

corrosive  sublimate  vaginal,  308. 
Dragging  caused  by  standing  posture, 

276. 
Drainage  of  bile  passages,  139. 

of  gall  bladder,  58,  132. 

intestinal,  182. 

supra-pubic,  334. 
Ductless  glands,  217. 
Ducts,  gall,  144. 

liver  and,  129-143. 
Duodenal    ulcer,    9,    10,    20,    21,    25, 
66,     68,     70,     71,     ^2,    73,     74, 
188,  250,  297. 

chronic,  123. 

perforation  of  a,  152. 
Duodenum,  stomach  and,  10,  9-27. 
Dysmenorrhea,  293. 
Dyspepsia,  9,  10,  65-74. 

acid,  17,  74. 

chronic,  69,  82,  182,  296. 

chronic,  indefinite,  165. 

confirmed,  233. 

nervous,  161. 
Dyspeptic,  24,  168. 

nervous,  144. 
Ear,  bleeding  from,  87,  88. 
Eating,  distress  immediately  after,  134. 
Eclampsia,  302. 
Edebohls,  172. 
Edema,  244. 

of  the  legs,  122. 
Effusion,  pleuritis  with,  108. 
Emergency  operation,  268. 
Empyema,  107-110. 
Endocarditis   165. 
Endometritis,  76. 
Enemata,  high,  182. 

nutrient,  19. 
Enlarged  spleen,  254. 


stomach,  246. 
Enteroptosis,      171,     175,     178,      188, 
217,239,297. 

and  Graves'  disease,  relation  between, 
217. 
Epididymis,  swollen,  317. 
Epididymitis,  323. 

traumatic,  317. 
Epigastric  pain,   20,    144,  265;  severe, 

174. 
Epigastrium,  distention  in,  193. 

gnawing  pains  in,  168,  295. 

pulsation  in,  160. 
Epilepsy,  idiopathic,  32. 

Jacksonian,  87. 
Epileptic,  35. 

Epileptiform  convulsions,  31,  32. 
Equilibrium,  psychic,  32. 
Erosions,  79. 

Ether  anesthesia,   122;    a  depressant, 
80;  prostration,  246. 

jacket,  80. 

pneumonia,  80. 
Ethical  interest,  313. 
Euthanasia,  27,  214. 
Eye-grounds,  85. 
Eyes,  prominent,  50. 
Examination,  cystoscopic,  311. 

by  rectum,  109,  306. 
Exploratory  laparotomy,  37-39. 

operation,  149,  160,  236,  330. 
External  meatus,  89. 
Extirpation  of  colon,  289. 
Extract,  thyroid,  149. 
Extra-uterine  pregnancy,  153,  157. 
Fecal  stasis,  239. 

stream,   absorption  of  water  from, 
186. 
blocking  of,  165. 
Fermentation,  217. 

gastric,  18. 

intestinal,  165,  179. 
Fever,  typhoid,  254. 
Fibrillary  tremor,  216. 
Fibro-cystadenoma,  50. 
Fibro-epithelial  tumors,  50. 
Fibroid,  294. 
Fibroma,  periductal,  50. 
Finney's  method,  21. 
Fistula,  anal,  313, 


INDEX. 


347 


recto-vaginal,  in,  112. 
Flaccid  hands,  296. 
Flexure,  hepatic,  prolapse  of,  161. 

splenic,  kink  at,  161. 
obstruction  at,  161. 
tenderness,  327. 
Flow,  267,  269. 

irregular,  153. 

pain  preceding,  45,  293. 

severe,  199,  280. 

uterine,  excessive,  273. 
Floyd,  Cleaveland  F.,  319,  320. 
Flush,  216. 

with  pain,  311. 
Food,  bolt,  191. 

pain,     constant    abdominal,     aggra- 
vated by,   159. 
an  hour  after,  136. 

three  hours  after,  70,  71,  72,  124. 

relieved  by,  295,  296. 
Forearm,  bones  of,  II4. 
Fossa,  anterior,  87. 

middle,  88. 

posterior,  94,  fracture  of,  87. 
Fowler's  position,  250. 
Fracture,  greenstick,  113. 

of  the  base,  86,  87. 

of  posterior  fossa.  87. 

of  skull,  86,  94. 

subperiosteal,  113. 
Fulminating  peritonitis,  1 10. 
Fundus  of  uterus,  237. 
Gall  ducts,  144. 
Gall  bladder,  265. 

burning  in,  137. 

drainage,  58,  132. 

enlarged,  145. 

inflammation,  chronic,  of,  141. 
Gallstones,  57,  174,  188. 

behind  sheath  of  rectus,  265. 

pain,  radiating,  due  to,  141. 
Gas  and  oxygen,  222,  330. 
Gastritis,  acid,  73. 
Gastro-mesenteric  ileus,  246. 
Gastrectasia,  17,  22. 
Gastric  fermentation,  18. 

distress,  24. 

stasis,  20. 

tympany,  196. 


ulcer,    19,    21,    70,    167,    173,    191; 
acute,  20;  chronic,  20. 
Gastrocolic  omentum,  11. 
Gastro-enteroptosis,  273. 

congenital,  165. 
Gastro-enterostomy,  9,  10,   15,   18,  22, 

67,  74;   anterior,  26. 
Gay,  G.  W.,  53- 
Genito-urinary,  321-324,  333-337- 

tuberculosis,  31 1. 
Gestation,  1 51-157. 
Glands,  ductless,  217. 

retro-peritoneal,  257. 

thyroid,  209. 
Glandules,  parathyroid,  204,  207. 
Gnawing  pains  in  epigastrium,  168. 
Goiter,  203,  206,  209,  210,  225,  227, 
230,  231. 

cystic,  204,  207. 

degeneration  of  a  hyperplastic,  227. 

Goldthwait,  J.  E.,  175. 

Gonorrhea,  99,  270,    314;  acute,    322. 

Graves'    disease,    50,    203,    204,    207, 

210,    213,    216,    220,    222,    223, 

226,  227,  228,  273,  281. 

acute,  209,  215. 

and  enteroptosis,   relation  between, 
217. 

symptoms  of,  221. 
Greenstick  fracture,  113. 
Guaiac  test,  11,  24,  66. 
Guinea-pig,  inoculated,  320. 
Gumma,  335,  336. 
Hands,  flaccid,  296. 

tremble,  160,  203. 
Harrington,  F.  B.,  318. 
Head,  85-95. 

injury,  88. 
Headache,  choked  disk,  and  vomiting, 
336. 

blindness  and   vomiting,    "  trilogi'," 
86. 

morning,  and  nausea,  124. 

sick,  9,  188. 

sub-occipital,  82. 
Heart,  246. 
Heartburn,  17,  18. 
Hematoma,  retro-peritoneal,  294. 

subperiosteal,  119. 


348 


INDEX. 


Hematuria,  causes  of,  38. 
Hemoglobin,  273. 
Hemorrhage,  73,  153,  303. 

acute,  306. 

from  bladder,  37. 

from  ears,  88. 

from  rectum,  41. 

secondary,  80,  270. 
Hemorrhagic    infarcts   of   the    kidney, 

acute,  105. 
Hepatic  flexure,  prolapse  of,  161. 
Hernia,  121-128,  251-257. 

inguinal,  127;  double,  127. 

internal,  331. 

pelvic,  270. 

post-operative,  11. 

strangulation  of,  122. 

umbilical,  125,  127. 
Houston's  valves,  311. 
Hydrobromate   of    quinine,    211,    221, 

225,  228. 
Hydrocele,  323. 
Hygiene,  improved,  191. 
Hyperchlorhydria,  10,  58,  73,  300. 
Hypernephroma,  145. 
Hyperthyroidism,  220,  222. 
Hypertrophy,  intra-alveolar,  227. 
Hypochlorhydria,  18. 
Hypochondrium,  pain  in  the  right,  134. 
Hysterectomy,  281. 

supravaginal,  270. 
Idiopathic  epilepsy,  32. 
Ileum,   implanting,   into   the   sigmoid, 
186,  289. 

expansion  of  lower,  186. 
Ileus,  gastro-mesenteric,  246. 
Immunity,  246. 
Impressions,  psychic,  14. 
Incision,  Kocher,  207. 

low  McBurney,  239,  240. 

Pfannensteil,  32,  46. 

retro-peritoneal,  309. 

transverse,  46. 
Indigestion,  24,  243-257. 

chronic,  233-241. 

intestinal,  132. 

several  hours  after  eating,  296. 
Infarct,  99. 

acute  hemorrhagic,  of  kidney,  105. 

acute  septic  hematogenous,  99. 


Infected  ligature,  257. 

tonsil,  239. 

ureter,  99. 
Infection,  acute,  29-30. 

ascending  urinary,  99. 

postpartum,  99. 
Inguinal  hernia,  122;  double,  127. 
Injury,  head,  88. 
Inoculated  guinea-pig,  320. 
Inoperable  cancer,  53. 
Insomnia,  203. 
Intermenstrual  pain,  294. 
Interstitial  pregnancy,  157. 
Intestinal,  111-112. 

drainage,  182. 

fermentation,  165,  179. 

indigestion,  132. 

obstruction,   287-290,    289,   330;   in 
young  persons,  289. 

perforation,  42. 

ptosis,  327,  331. 

stasis,  217. 
Intestine,  malignant  disease  of,  236. 

prolapsed,  167. 

short-circuit,  176. 
Intoxicants,  thyroid,  213. 
Intra-alveolar  hypertrophy,  227. 
Intracranial  pressure,  86,  88,  94. 
Intussusception,  331. 
Iodide  of  potash,  204,  336. 
Iodine,  compound  solution  of,  53. 
Jacket,  ether,  80. 
Jacksonian  convulsions,  87,  90. 
Jaundice,  134,  141,  171;    chronic,  149. 
Kidney,  97-105. 

diseased,  damage  to,  246. 

floating,  168,  171,  178. 

infarct,  acute  hemorrhagic,  of,  105. 

prolapse  of  right,  145,  160. 

pus,  99. 

sarcoma  of,  39. 

septic,  98. 

surgical,  99. 

tumor,  38,  98,  99,  145. 
Kink,  colonic,  175. 

splenic,  176,  327. 
Kocher  incision,  207. 
Labor,  myomatous  mass  complicating, 

284. 
Laceration  of  brain,  87. 


INDEX. 


349 


of  rectus  muscle,  117. 
Laparotomy,  exploratory,  37-39. 
Laryngeal  nerve,  recurrent,  207. 
Leg,  edema  of,  122. 
Leucorrhea,  76,  302. . 
Lids,  lagging,  50. 
Ligament,  shortening  of  the  round,  201. 

of  Treitz,  22. 
Ligation  of  superior  thyroid  arteries, 

229,  230. 
Ligature,  infected,  257. 
Lip,  carbuncle  of  upper,  30. 
Liver  and  ducts,  129-143. 

malignant  disease  of,  149. 
Loin,  pain  in  the  right,  309. 
Lump  in  breast,  47. 
Malaria,  17;  chronic,  38. 
Malignant  characteristics,  51. 

disease  of  intestine,  236. 

disease  of  bile  passages,  pain  of,  136. 

disease  of  liver,  149. 

tumors,  48. 
Malingering,  278. 
Mass  in  region  of  cecum,  236. 

in  liver,  236. 
Massachusetts    General    Hospital,    9, 
19,   22,   55,   87,    109,  204,   228, 
277,  287,  321,  326. 
Massage,  322. 

Mastication,  improper,  167. 
Mayo,  C.  H.,  214. 
McBurney  incision,  low,  239,  240. 
Means,  persons  of  limited,  262. 
Meatus,  external,  89. 
Melancholia,  279. 
Melancholy,  13. 
Membrane,  Cargile,  331. 
Memory,  recovery  of,  92. 
Meningeal  cysts,  91. 
Meningitis,  95. 
Menstruation,  irregular,  50. 
Mental  depression,  175. 

disturbance,  280. 

symptoms,  299. 

treatment,  52. 
Mesenteric  thrombosis,  250. 
Mesentery,    abnormality    of,    curious, 
328. 

abnormally  long,  161. 
Metritis,  302. 


Micturate,  desire  to,  333. 
Minot,  J.  J.,  109. 
Miscarriage,  270,  302. 
Morose,  233. 
Morris,  R.  T.,  58. 

point,  262. 
Motor  area,  87. 
Mouth,  bleeding  from,  87. 
Movement,  pain  aggravated  by,  259. 
Moynihan,  B.  G.  A.,  69. 
Mucous  colitis,  31,  32,  161,  179,  182. 
Multiple  operations,  325. 
Munro,  J.  C,  309. 
Murphy,  F.  T.,  176. 
Murphy,  J.  B.,  250. 
Muscle,  rectus,  laceration  of,  117. 

sphincter  ani,  60. 
Muttering,  85. 
Myoma,  76,  270,  273,  275. 

obstructing,  284. 

of  pregnancy,  284. 
Myomatous  mass  complicating  labor, 

284. 
Myxoma,  periductal,  50. 
Nausea,  173. 

constant,  168. 

morning  headache  and,  124. 
Navel,  tenderness  near,  57. 
Nephritis,  244. 
Nephropexy,  lOi. 
Nerve,  cutting  of  the  ovarian,  294. 

optic,  85. 

recurrent  laryngeal,  207. 
Nervous,  203, 

breakdown,  178. 

dyspepsia,  144. 

dyspeptic,  161. 

and  mental  disturbance,  280. 
Nervousness,  227. 
Neuralgia,  ovarian,  45,  46,  293. 
Neurasthenia,  75,  100,  216. 
Neuritis,  246. 

general,  244. 
Neuroses,  310. 
Nitrous  oxide,  113,  115. 

and     oxygen,     80,     125,     213,     245, 
246,  281. 
Nodes  in  axilla,  47. 
Nutrient  enemata,  19. 
Obstructing  adhesions,  330. 


350 


INDEX. 


myoma,  284. 
Obstruction,  331. 

at  splenic  flexure,  165. 

intestinal,  330. 

portal,  149. 

pyloric,  14,  18,  25,  67,  68. 

treatment  of,  262. 
Omental  stump,  tying  off,  123, 
Omentum,  gastrocolic,  li. 

incarcerated,  122. 
Operations,  abdominal,  in  very  young 
children,   186. 

emergency,  268. 

exploratory.  149,  160,  236,  330. 

high,  for  disease  within  scrotum,  323. 

multiple,  127,  325. 
Oppler-Boas  bacilli,  24. 
Optic  nerve,  85. 
Orchidectomy,  323. 
Orchitis,  317. 
Osier,  Wm.,  38. 
Ovarian  cyst,  strangulated,  297;  twisted, 

157- 

nerves,  cutting  the,  294. 
neuralgia,  45,  46,  293. 
tumor,  279;  old-fashioned,  300. 
Ovary,  cystic,  274. 
Ovaries,  deprived  of  both,  282. 

tubes  and,  270. 
Oxygen,    nitrous    oxide   and,    80,  125, 

213,222,245,246,281,330. 
Pain,  abdominal. 

constant,  aggravated  by  food,  159. 
general,  109. 
indefinite,  325. 
recurring  attacks  of,  190. 
aggravated  by  movement,  259. 
an  hour  after  food,  136. 
below  the  right  costal  margin,  262. 
epigastric,  20,  144,  265,  295;  severe, 

174. 
flush  with,  311. 

gnawing,  in  the  epigastrium,  168. 
in  the  belly,  agonizing,  152. 
in  the  rectum,  308. 
in  the  right  hypochondrium,  134. 
in  the  right  loin,  309. 
in  the  splenic  region,  175. 
intermenstrual,  294. 
on  standing,  200. 


of    malignant    disease    of    the    bile 
passages,  136. 

ovarian,  293. 

overwhelming,  157. 

preceding  the  flow,  45,  293. 

radiating,  due  to  gallstones,  141. 

relieved  by  food,  295,  296. 

three  hours  after  food,  70,  124. 
Pain,  circulatory,  312. 
Pancreatic  apoplexy,  152. 
Pancreatitis,  250;  acute,  136;  chronic, 

149. 
Pan-hysterectomy,  208. 
Papillary  cystadenoma,  51. 
Paralyses,  42,  88. 
Para.thyroid  glandules,  204,  207. 
Parturition,  270. 
Patient,  terrified,  214. 
Pelvic  hernia,  270. 

viscera,  prolapse  of,  201. 
Pelvis,  291-304. 

as  the  source  of  all  disease,  297. 

adhesions,  deep  in  the,  269. 

peritonitis  of,  294. 

uterus  deep  in,  200. 
Perforated  abdomen,  41-43. 
Perforating  ulcer,  acutely,  74. 
Perforation,  73. 

intestinal,  42, 

of  appendix,  153. 

of  duodenal  ulcer,  152. 
Periductal  fibroma,  50. 

myxoma,  50. 

sarcoma,  50. 
Perineum,  76,  78,  80,  82,  ill. 

torn,  199. 
Periproctitis,  307. 
Peristalsis,  paralysis  of,  42. 
Peritonitis,  diffuse,  109. 

fulminating,  1 10. 

pelvic,  294. 
Pernicious  vomiting,  302. 
Persons  of  limited  means,  262. 

young,    chronic    intestinal    obstruc- 
tion in,  289. 
Perspire  easily,  209. 
Petrous  bone,  87. 
Pfannensteil  incision,  32,  46. 
Phantom  tumor,  300. 
Phosphaturia,  311. 


INDEX. 


351 


Pia-arachnoid,  thickening  of,  91. 
Plastic  resection,  51. 
Pleurisy,  107,  165. 
Pleuritis  with  effusion,  108. 
Pneumococci,  108. 
Pneumonia,  79,  80,  107,  182. 

ether,  80. 
"  Poop,"  119. 
Portal  obstruction,  149. 
Position,  Fowler,  250. 
Posterior  capsule,  stripping  the,  214. 

fossa,  87,  94. 

and  anterior  splints,  113. 
Post-operative  hernia,  li. 
Postpartum  infection,  99. 
Posture,  standing,  with  dragging,  276. 
Potash,  iodide  of,  204,  336. 
Pregnancy,  cutting  short,  302. 

extra-uterine,  153-157. 

interstitial,  157. 

ruptured  tubal,  153. 
Pressure  above  pubes,  297. 

intracranial,  86,  88,  94. 
Proctectomy,  112. 
Proctitis,  III,  306,  308. 
Proctoclysis,  43,  73,  250,  264,  270. 
Prognostic  evidence,  86. 
Prolapse  of  hepatic  flexure,  161. 

of  pelvic  viscera,  201. 

of  right  kidney,  160. 

of  uterus,  201. 
Prolapsed  colon,  168. 

intestines,  167. 

stomach,  160,  178. 

uterus,  199. 
Prone  position,  location  of  stomach  in, 

178. 
Prostration,  general,  174. 

of  ether  anesthesia,  246. 
Psychic,  281,  282,  321. 

equilibrium,  32. 

impressions,  14. 

influences,  217. 

state,  204,  273. 
Ptosis,  14,  15.  61,  70,  165,  182,  185,  196. 

belt,  197. 

congenital,  lOi,  274,  328. 

familiar  type  of,  169. 

intestinal,  327,  331. 

toxemia  of,  217, 


visceral,  32,  123,  161,  169,  175,  246. 
Pyloric  obstruction,  14,  18,  25,  67,  68. 

spasm,  58,  59,  66,  299. 
Pyloroplasty,  21,  22. 
Pylorus,  10. 
Pyonephrosis,  99,  102. 
Pulsation  in  epigastrium,  160. 
I^uncture,  vaginal,  298. 
Pus.  107. 

from  kidney,  99. 

green,  no. 
Quinine,    hydrobromate   of,    211,   221, 

225,  228. 
Rectocele,  82,  275. 
Recto- vaginal  fistula,  in,  112. 
Rectum,  blood  from  19,  20. 

examination  by,  109,  306. 

hemorrhage  from,  41. 

pain  in,  308. 
Rectus,  bulging  of,  63. 

gallstones  behind  sheath  of,  265. 

muscle,  laceration  of,  117. 

spasm  of,  109. 
Refiex  symptoms,  168. 
Reflexes,  85,  88, 
Remedies,  anti-syphilitic,  336. 
Renal  calculi,  99. 

tuberculosis,  319. 
Resection,  plastic,  51. 
Respiratory  center,  compression  of.  86. 
Retrocession   78. 
Retro-peritoneal  glands,  257. 

hematoma,  294. 

incision,  309. 
Rheumatism,  305. 
Richardson,  M.  H.,  306. 
Rogers  and  Beebe,  227,  228. 
Rose  spots,  254. 
"  Run  down,"  167,  191. 
Rupture  of  bowel,  153. 

of  stomach,  153. 

tubal,  153. 
Ruptured  tubal  pregnancy,  153. 
Sacro-iliac  disease,  308, 
Salpingitis,  302. 
Salts,  Carlsbad,  69. 

and  calomel,  250. 
Sarcoma  of  kidney,  39. 

periductal,  50. 
Scalp  wound,  88. 


352 


INDEX. 


Scaphoid  abdomen,  144. 
Sciatica,  280. 
Scrotum,  317-320. 

high  operation  for  disease  within,  323. 
Scybalous  constipation,  196. 
Secondary  anemia,  38. 

hemorrhage,  80,  270, 
"  Seepage,"  250. 
"  Seizures,"  31-36. 
Semi-consciousness,  85. 
Septic,  acute,  hematogenous  infarct,  99. 
Septicemia,  acute,  105. 
Shattuck,  F.  C,  38. 
Sheep's  dung,  327. 
Shock,  23. 

Short-circuit  the  intestine,  176. 
Shortening  the  round  Hgaments,  201. 
Shortness  of  breath,  160,  203. 
Sigmoid,  anastomosing  cecum  to,  161. 

implanting  ileum  into  sigmoid,  186, 
289. 
Sinus,  abdominal,  257. 
Skin,  dry,  160. 
Skull,  fracture,  of,  86,  94. 
Spasm  of  the  rectus,  109. 

pyloric,  58,  59,  66,  299, 
"  Spells,"  dizzy,  34,  35. 
Sphincter,  dilating  the,  307. 
Sphincter  ani,  56,  58. 

muscle,  60,  63. 
Spinal  anesthesia,  123. 
Spleen,    38. 

enlargement  of  the,  254. 

tumor  of,  39. 
Splenic  flexure,  kink  at,  161. 

kink,  176,  327. 

obstruction  at,  165. 

region,  pain  in,  175. 

tenderness,  327. 
Splints,    anterior   and    posterior,    113. 

internal  angular,  113. 
Staphylococcus  aureus,  29. 
Starvation,  20. 
Stasis,  fecal,  239. 

gastric,   20. 

intestinal,  217. 
Stercoral  ulcer,  265. 
Sterility,  45-46. 
Stertorous  breathing,  85,  86. 
Stomach  and  duodenum,  9-27, 


cancer  of,  24,  26. 

enlarged,  246. 

location  of,  in  prone  position;  178., 

prolapsed,  160,  178. 

rupture  of,  153. 

x-rays  of  stomach  and  colon,  274. 
Stools,  analysis  of,  159. 

blood  in,  66. 

examination  of,  236. 
Strabismus,  divergent,  85. 
Strangulated  ovarian  cyst,  297. 

testicle,  317. 
Strangulation  of  hernia,  122. 
Stream,  fecal,  blocking  of,  165;  absorp- 
tion of  water  from,  186. 
Stricture,  organic,  334. 
Stump,  cervical,  suspension  of,  270. 

omental,  tying  off,  123. 
Stupor,  86. 

Sub-occipital  headache,  82. 
Sub-periosteal  fracture,  113. 

hemotoma,  119. 
Suicide,  threatened,  279. 
Supports,  abdominal,  250. 
Supra-pubic  drainage,  334. 
Supra-vaginal  hysterectomy,  270. 
Surgical  kidney,  99. 
Suspension  of  cervical  stump,  270. 

of  uterus,  79. 
Sweat,  216. 

Swelling  of  right  testicle,  317. 
Symptoms,  appendicitis,  17. 

mental,  299. 

of  Graves'  disease,  221. 

reflex,  168. 
Syncope,  14. 

Syphilis,  131,  137,  204,  335. 
Syphiloma,  335,  336. 
Tachycardia,  50,  211,  227. 
Teeth,  bad,  167. 
Temperament,  changes  of,  179. 
Temperature,  range  of,  86. 
Tenderness  near  navel,  57. 

of  splenic  flexure,  327. 

superficial,  331. 
Tenesmus,  308. 
Test,  guaiac,  II,  24,  66. 
Testicle,  strangulated,  3x7. 

swelling  of,  317. 

tuberculous,  320. 


INDEX. 


353 


Thickening  of  pla-arachnoid,  91. 
Thoracic  disease,  1 10. 
Thrombosis,  mesenteric,  250. 
Thyroid,  207,  216. 

arteries,  superior,  ligation  of,  229, 230. 

dessicated,  227. 

extract,  149. 

gland,  209. 

intoxicants,  213. 
Thyroidectomy,  222. 
Tongue,  biting  of,  31. 

furred,  160. 
Tonsillitis,  165. 
Tonsils,  infected,  239. 
Toxemia,  chronic,  165. 

general,  185,  246. 

occult,  185, 

of  ptosis,  217. 
Toxemias,  203-231. 
Treatment,  antacid,  299. 

anti-malarial,  39. 

mental,  52. 

of  obscure  cases,  262. 

vaccine,  303. 
Treitz,  ligament  of,  22. 
Trembhng  hands,  203. 
Tremor,  50,  227. 

fibrillary,  216. 

of  hands,  160,  203. 
"  Trilogy,"    headache,    vomiting    and 

blindness,  86. 
Tropics,  37. 
Tubal  abortion,  153,  157. 

disease,  294. 

pregnancy, ruptured,  153. 
Tubes,  79,  99. 

and  ovaries,  270. 

diseased,  80. 
Tuberculin,  311,  318. 
Tuberculosis,  254,  257, 

genito-urinary,  311. 

renal,  319. 
Tuberculous  testicle,  320. 
Tubo-ovarian  cyst,  240. 
Tumor,  benign,  48. 

brain,  335,  336. 

breast,  nature  of,  48. 

fibro-cystadenoma,  50. 

fibro-epithelial,  50. 

kidney,  38,  98,  99,  145. 


malignant,  48. 

ovarian,  279;  old-fashioned,  300. 

phantom,  300. 

periductal  fibroma,  50. 

periductal  myxoma,  50. 

periductal  sarcoma,  50. 

spleen,  39. 

uterus,  270,  278,  280. 
Turkish  bath,  322. 
Tympanum,  88. 
Tympany,  gastric,  196. 
Typhoid  fever,  254. 
Umbilical  hernia,  125,  127, 

ring,  126. 
Ulcer,    duodenal,    9,    10,    20,    21,    25, 
66,  68,  70,  71,  72,  73,  188,  250, 
297;  chronic,   123. 
perforation  of,  152. 

gastric,     19,    21,    70,    72,    74,    167, 
173,  191;  acute,  20. 

perforating,  acutely,  74. 

stercoral,  265. 
Unconscious,   34. 
Unconsciousness,  86. 
Ureter,  98,  99. 

calculus  in,  157. 

infected,  99. 
Ureteral  calculus,  105,  306;  impacted, 

262. 
Urethra,  false  passages  in,  334. 
Urethritis,  99,  322. 
Urinary,  ascending,  infection,  99. 
Urine,  bloody,  37,  42. 

suppression  of,  105. 
Urotropin,  99. 
Uterine  flow,  excessive,  273. 

tumor,  278,  280. 
Uterus,  82,  283-285. 

deep  in  pelvis,  200. 

fundus  of,  237. 

prolapse  of,  199,  20I0 

suspension  of,  79. 

tumor  of,  270. 
Vaccine  treatment,  247,  257,  303. 
Vaginal   douche,   corrosive   sublimate, 
308. 

puncture,  298. 
Valves,  Houston's,  311. 
Vasomotor  center,  irritation  of,  86. 
Venereal  disease,  313. 


354 


INDEX. 


Viscera,  pelvic,  prolapse  of,  201. 
Visceral    ptosis,    32,    123,     161,     169, 

175,  246. 
Vision,  blurring  of,  14,  50,  160. 
Volkmann's  contracture,  114. 
Volvulus,  250,  331. 
Vomit,  13,  14. 
Vomiting. 

bilious,  275. 

headache,  and  blindness,  "  trilogy," 
86. 

headache,  choked  disk  and,  336. 


of  blood,  19. 

pernicious,  302, 
Warren,  J.  C,  307. 
Weeping,  228. 

easily,  216. 
Wells,  Spencer,  era.  .300. 
Whitney,  William  F.,  118,  227. 
Wound,  scalp,  88. 
X-rays   of   stomach   and    colon,    159, 

173,    176,  181,   183,  188,   194,    196, 

274,  287. 


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